Every finding on record at Mccrite Plaza at Briarcliff Skilled Facility

Based on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to maintain sanitary conditions during food preparation and failed to label and properly store food items. This affected all residents in the facility. The facility census was 44. Review of facility policy, Handling Leftover Food, dated 1/21/26, showed:- Leftover foods will be properly handled, cooled, and stored to ensure food safety minimal waste.- Leftover foods stored in the refrigerator shall be wrapped, dated, labeled with an open date/or use by date that is no more than 72 hours from the time of the first use. - Refrigerated leftovers stored beyond 72 hours shall be discarded. Some food items will be stored for more than 72 hours (refer to Safe Food Storage: the Refrigerator and Freezer chart)- Leftover foods stored in the freezer shall be wrapped airtight and moisture proof, dated and labeled.Review of facility policy, Food Storage (Dry, Refrigerated and Frozen), dated 1/21/26, showed:- Food shall be stored on shelves in a clean, dry area, free from contaminants.- All food items will be labeled. The label must include the date the food item was opened and/or the date by which it should be consumed or discarded.- Discard food that has passed the expiration date.- Leftover content of cans and prepared food will be stored in covered, dated containers in refrigerators and/or freezers.- Chemicals will be stored separately from food. Preferably chemicals will be store on the bottom shelf.Review of facility policy, Dietary Procedures, undated, showed Staff will wash hands in hand washing sink before handling food or equipment in the kitchen then put on a clean apron.Review of facility policy, Safe Food Storage: The Refrigerator and Freezer, dated April 2014, showed canned vegetables can be stored up to four days in a refrigerator after opening;Review of facility policy, Food Sanitation Procedures, not provided.1. Observation in the kitchen on 4/21/26 at 9:10 A.M., showed:- Walk-in Freezer had four packages of breaded patties had no labeling or date annotated;- Walk-in Freezer had eight loose bags of deep-fried frozen items with no labeling or dates annotated;- Dry Storeroom had de-[NAME] acidic cleaning agent stored on an adjacent shelf six inches away from three cases of packaged pudding;Walk-in Refrigerator:- Two metal pans containing 20 pounds of cooked meat were uncovered and not labeled;- Heavy whipping cream in a one-quart cardboard container was opened and resealed with no dates annotated;- Six packages of loose butter (16 ounces each) had no date annotated;- Two packs of hard-boiled eggs, loose, had no labeling and no date annotated; - Leftover peaches in a tin container had no date annotated;- Mushrooms uncooked in a plastic bag dated 4/15 (expired);- Eight ounces of meat in an unlabeled plastic bag and dated 4/20;- An unlabeled dessert in a plastic container with no label dated 4/8;- Three bags of unknown leftovers dated 4/20;During an interview on 4/21/26 at 9:40 A.M., the Dietary Manager (DM) said:- The uncovered meat was prepared on the evening shift for lunch on 4/21/26. It was pork butt and should have been covered and labeled by the evening staff when it was put into the refrigerator. - The leftover mushrooms are from an opened can used on 4/15/26 and they have a seven-day shelf life according to vegetables on the leftover policy.Observation in the Dining Room on 4/21/26 at 12:00 P.M., showed:- The dining room contained an open-air kitchen preparation area about 15 feet from the nearest dining table separated by a waist high wall and door going into the kitchen area. Staff prepared individual meal trays for the residents in the kitchen area and passed them over the wall to dining room staff. Some food preparation occurred on a three-foot ledge along the outside perimeter of the kitchen. There are no sneeze shields or barriers between residents and the staff working on the outside ledge area. Staff maintain hairnet procedures in this area when doing food preparation. - DM prepared guacamole for the residents by scooping a serving out of a large plastic container and filling individual sized serving cups. - A family member approached the kitchen wall and reached over the food preparation area and directly over the open container of guacamole to get a food tray from kitchen staff. The family member did not hand wash or wear a hair net prior to entering the kitchen preparation area- Kitchen Manager (KM) serves resident meals and while retrieving trays from the counter and had arms directly over the open container of guacamole.- Dietary Aide (A) served residents in the dining room and back to the kitchen preparation task of putting tortilla chips into resident cups of guacamole without hand washing. Observation in the Kitchen on 4/22/26 at 10:15 A.M., showed Refrigerator had a metal container filled with a white topping labeled SH Cheese and dated 4/21;During an interview on 4/22/26 at 10:25 A.M., the DM said that the container labeled SH Cheese was labeled incorrectly and was sour cream from yesterday's meal and was sent back to the main kitchen from the upstairs kitchen.Observation in the Dining Room on 4/22/26 at 12:00 P.M., showed:- KM is wearing gloves and serving residents in the dining room. - 12:20 P.M. KM observed touching non-food surfaces such as dining room chairs and resident napkins during meal service to residents. KM switched roles to food preparation by plating individual slices of pumpkin pie without changing gloves and hand washing.- Whipped topping in an icing bag is brought to the food preparation area in the dining room from the downstairs kitchen by the RD. The MDS coordinator who was previously serving resident meals in the dining room, took the icing bag from the RD without hand washing and applied icing to individual plated pumpkin slices in the food preparation area. During an interview on 4/23/26 at 9:20 A.M., the Registered Dietician (RD) said:- She does on the job training with staff on hand washing and cooking hygiene procedures.- Food items in the freezer and refrigerator should have dates of receipt on the products which is normally provided by the supplier. Items should have open dates or use by dates when they are resealed and placed back into the freezer or refrigerator. Loose items taken out of cases should have the receipt date written on them. - De-[NAME] and other cleaning solutions are allowed to be stored within six inches of food items provided they are on another storage rack.- Meats that are cooked in advance of the next day's meal should be stored with the cook date and should be covered in the refrigerator.- Cooked leftover items are good for three days.- A leftover policy for most food items is provided to the staff in the form of a eight page handout from a regional University and adopted as the facility's policy.- Staff should hand wash between glove changes.During an interview on 4/23/26 at 10:00 A.M., the Director of Dining Services said:- The kitchen area in the dining room is very limited, so staff have to do some preparation work on the ledge between the kitchen and where the residents are eating. - Family members or residents should not be at the kitchen pass area and should not be reaching over food items being prepared. - Staff members should not be handling food or doing food preparation without proper handwashing. During an interview on 4/24/26 at 9:10 A.M., the Administrator said:- Labels on food items should show the date received which normally comes from the supply vendor. If the item is removed from the case each item needs to have the received date annotated. If an item is opened and resealed the open date needs to be annotated.- Hazardous cleaning agents such as de-[NAME] need to be stored away from food products and six inches is not enough clearance between food and cleaning agents. A few feet would be acceptable.- Cooked meat should be stored and covered, dated and labeled in the refrigerator.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when the facility failed to ensure staff wore appropriate protective equipment when providing care to residents that required enhanced barrier precautions (EBP) to prevent transmission of diseases and infections to residents that are at a higher risk for infection for two residents (Resident #8, #20); failed to keep a catheter drainage bag off of the floor for one resident (Resident #13);failed to change gloves during cares between clean and dirty tasks (Resident #4) and additionally when the facility staff failed to follow handwashing requirements when serving residents in the dining room. This affected four of 12 sampled residents.The facility census was 44.Review of the facility's undated Infection Control Policy showed that all staff, whether employed by facility or contracted agency staff, are responsible for complying with infection control precautions and protocols. Review of the facility's undated Enhanced Barrier Precautions Policy showed: -EBP are implemented as an intervention this facility uses to reduce transmission that employs targeted personal protective equipment (PPE) use during high contact resident care activities; -Chronic wounds may include pressure ulcers diabetic foot ulcers and venous or arterial ulcers; -Indwelling medical device refers to an indwelling medical device that can provide a direct pathway for pathogens in the environment to enter the body and cause infection, examples include urinary catheters, central lines and feeding tubes; -Providing hygiene refers to practices such as brushing teeth, combing hair, dressing, bathing, transferring, changing briefs or assisting with toileting including perineal care, device care (emptying or manipulating catheter, central line, etc), and wound care; -All staff will be trained and in-serviced and will demonstrate competency at time of hire, before providing direct patient care to any resident, annually and as determined by facility. Review of the facility's undated Indwelling Catheter Protocol Policy showed: -Position the bag to avoid urine backflow into the bladder, kinking or gross contamination of the bag -Never allow the bag or tubing to touch the floor; -Because of the danger of infection with a catheter, the equipment should be handled aseptically (free from living pathogens or microorganisms that can cause infection). 1.Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 3/25/26, showed: -Severe cognitive impairment; -He/She had a nephrostomy tube (a thin, flexible tube surgically inserted through residents back and into the kidney to bypass urinary tract blockages); -Diagnoses included kidney disease, high blood pressure and Non-Alzheimer's Dementia. Review of the resident's care plan, dated 9/17/25, showed: -He/She required EBP related to the nephrostomy tube; -He/She was on a prescribed oral antibiotic for an active urinary infection; -He/She required assistance from facility staff for hygiene, toileting and walking. Observation on 4/22/26 at 8:04A.M., showed LPN C providing cares and assisting the resident with toileting, toileting hygiene and dressing while wearing only gloves. During an interview on 04/22/26 at 8:10A.M., LPN C stated that residents with a nephrostomy tube require EBP and that he/she should have been wearing a gown while assisting the resident with personal hygiene and toileting to protect resident from infection. 2. Review of Resident #13's Comprehensive MDS dated [DATE], showed: -No cognitive impairment; -He/She had an indwelling catheter (a flexible tube placed into the bladder and connected to a bag, to drain and collect urine); -Diagnoses included high blood pressure, arthritis, neurogenic bladder and stroke. Review of the resident's care plan dated 2/4/25 showed: -He/She required EBP related to indwelling urinary catheter; -He/She was dependent on staff for hygiene, grooming, dressing and transfers; -Staff to keep catheter drainage bag below level of resident's bladder and ensure tubing free of kinks and complications each shift and as needed. Observation on 4/22/26 at 8:28 A.M., showed LPN C and CNA C transferring Resident #13 using a mechanical lift and catheter dependent drainage bag was placed directly on the floor by CNA C. Observation of resident on 4/22/26 at 8:28A.M., during am care the resident said to CNA C and LPN C: -He/She had never seen the disposable gowns before and wondered why staff were wearing them. -He/She said Are those gowns new, you usually don't wear than, is something going around? During an interview on 04/22/26 at 9:10A.M., CNA C said that he/she knows that the urinary drainage bag is not to be directly placed on the floor to keep drainage bag and tubing clean, and he/she had cleaned the drainage bag prior to placing drainage bag into dignity bag During an interview on 04/24/26 at 10:40A.M., the Director of Nursing (DON) said: -Protective equipment including gloves and gowns are to be worn by staff when providing hygiene, grooming or transferring a resident that required EBP: -Catheter drainage bags should never be placed directly on the floor; -If the catheter bag needs to be put on the ground during a transfer or care for patient safety, then a barrier should be placed on the ground to assist in the prevention of transmission of bacteria; -EBP is used to protect residents at an increased risk for infection, such as a residents with an indwelling catheter, a central line (a long, thin tube inserted into a large vein, usually in the arm, that extends into a major vein near the heart, used for administration of mediations and fluids), or chronic wounds. 3. Review of Resident #20's Quarterly MDS dated [DATE], showed: -No cognitive impairment; -He/She had multiple venous or arterial ulcers (slow-healing, chronic, painful, shallow sores typically on lower legs); -He/She was always incontinent of bowel and bladder; -Diagnoses included heart failure, kidney disease and malnutrition. Review of the resident's care plan dated 6/11/25, showed: -He/She required EBP related to chronic leg wounds; -He/She had physician ordered daily wound treatments; -He/She required extensive assist from nursing staff for dressing, grooming, bathing and personal hygiene. Observation on 04/22/26 at 12:56P.M., showed CNA C providing peri care and personal hygiene including face washing and hair care to the resident without wearing a disposable isolation gown. Observation on 04/23/26 at 10:07A.M., showed CNA E providing peri care, perineal hygiene and repositioning the resident when in bed wearing gloves only, no gown. During an interview on 04/22/26 at 9:45A.M., the resident said that staff do not wear gowns when assisting him/her with incontinence/peri cares and additionally, staff do not wear gowns when dressing/bandaging his/her leg wounds. During an interview on 04/22/26 at 1:10P.M., CNA C said he/she did not think that staff needed to wear EBP when providing peri care to the resident as his/her leg wounds were bandaged/covered. During an interview on 04/23/26 at 10:10A.M., CNA A said that EBP is meant to protect residents from infection and that he/she should have worn a gown while providing care to the resident. During an interview on 04/24/26 at 10:40A.M., the Infection Preventionist/Assistant Director of Nursing said that staff are required to wear gowns and gloves when providing hygiene, grooming, toileting or transferring of residents that require EBP for their protection against infection. Review of undated Perineal care protocol policy showed staff are to wash, rinse, and dry buttocks and peri-anal area without contaminating the perineal area. 4. Review of Resident #4's admission MDS, dated [DATE] showed: -Limited range of motion affecting one of his/her legs. -Dependent on staff for toileting, bathing and lower body dressing. -Required maximum assistance to change positions and transferring bed to chair. -Incontinent of both bowel and bladder. -At risk for pressure ulcers. Review of the care plan dated 04/13/26 showed: - He/She was dependent on two nursing staff for toileting, dressing lower half of body and transfers -He/She was dependent on nursing staff for all personal hygiene, grooming, and incontinent care. -The resident had a history of urinary tract infections, most recently 04/18/26. During an Interview and Observation of incontinent care on 04/22/26 at 10:09 A.M. showed: -The resident laid on the bed, turned on call light. CNA A answered resident's light. Resident said he/she was wet and had not been changed since 9:00 p.m. the previous night. Resident said he/she felt humiliated to be left in a wet brief this long. -Incontinent brief was soiled all the way through to the outer lining of the disposable incontinent pad that was placed on the bed under the resident's bottom. The top sheet and the blanket were also soiled with urine. The disposable incontinent pad had a dried dark yellow ring with a lighter yellow ring of urine closer to the center of the pad, indicating it had been there for some time. The center of the pad was heavily saturated with urine. -CNA A applied gloves, unfastened the brief tucking down and tucking the right side of brief and disposable pad under resident. Cleansed perineal area down left side using one wipe, right side using a second wipe, then middle using a third wipe and assisted Resident to roll onto the right side. Then removed the brief and disposable pad from under resident and placed brief and pad into the trashcan. Removed gloves, placed them in the trash can and performed hand hygiene and applied a clean set of gloves and tucked clean brief and pad under resident. Applied barrier cream on coccyx and buttocks including the open wound then applied barrier cream to resident's abdominal fold and perineal area without changing gloves. During an interview on 04/22/2026 at 10:20 A.M. CNA A said: -Resident #4 should be checked for incontinence and repositioned every two hours. -He/She should have changed gloves prior to placing barrier cream on the perineal area and abdominal fold to prevent spreading bacteria from the resident's buttocks to the urinary tract. -He/She should not have placed barrier cream on the open buttock wound. During an interview on 04/22/26 at 02:15 P.M. LPN A said: -He/She would expect Resident #4 to be repositioned, and incontinent care provided every two hours. -He/She would not expect a CNA to place barrier cream on a resident's bottom and then the front folds without changing gloves as this spread's bacteria. -He/She would not expect a CNA to place barrier cream on an open wound as it could damage healing skin and cause infection. During an interview on 04/24/26 at 10:15 A.M. the DON (Director of Nursing) said: -She expects incontinent residents to be provided with incontinent care every two hours and as needed. -She would expect CNAs to place barrier cream around an open wound not on the wound as this could damage the healing wound bed. -She would not expect a CNA to place barrier cream on a resident's buttocks then place it on the abdominal fold and perineal area without changing gloves since doing so can spread unwanted bacteria. During an interview on 04/24/26 at 11:15 A.M. the Administrator said: -She expects dependent residents to be repositioned every two hours. -She would not expect a CNA to place barrier cream on an open wound as this can damage the healing wound bed and cause infection. -She would expect CNAs to change their gloves between applying barrier cream to the peri-anal region and the perineal region. 5.Observation of the Dining Room on 4/21/26 at 11:25 A.M., showed:- Kitchen Manager (KM) wearing gloves served multiple residents and touched chairs and resident napkins and no hand sanitizing between serving resident meals after touching non-food contact surfaces.- KM removed gloves, touched hair with un-gloved hand, served desserts without hand sanitizing. Observation of the Dining Room on 4/22/26 at 12:00 P.M., showed KM served several residents meal trays and touched resident napkins, back of one resident's chair, moved a chair which a resident had been sitting in, and did not hand sanitize between serving residents. During an interview on 4/23/26 at 9:20 A.M., the Registered Dietician (RD) said staff should hand sanitize between serving residents when their hands become soiled. Running a hand through hair would require hand sanitizing when serving meals. During an Interview on 4/23/26 at 1:15 P.M., Dietary Aide (A) said:- When serving residents in the dining room staff should sanitize their hands every five minutes or if their hands become soiled, whichever comes first.- If a staff member touches their hair they should hand sanitize before serving a resident even if they are wearing gloves. During an interview on 4/24/26 at 9:10 A.M., the Administrator said kitchen and dining room staff need to sanitize their hands before serving residents and re-sanitize if their hands become soiled. Running your hands through your hair would require hand sanitizing. Also touching a resident or non-food contact surface would require hand sanitizing between residents.

Based on observation, interview and record review, the facility failed to ensure proper storage and labeling of medications and biologicals when the facility had an open bottle of lorazepam (an anti-anxiety medication) with no open date for one resident (Resident #45); opened multi-use vials of eye drops with no open date for two residents (Resident #6, #36), opened and un-dated multi-use bottles of nose spray for two residents (Resident #6 & discharged resident #52), un-dated multi-dose vial of ear drops (Resident #21), and additionally when the facility had two opened, un-dated glucose control solution (solution used for daily calibration/testing of bedside blood glucose machines). This affected five of 14 sampled residents. The facility census was 44.Review of the facility's undated Medication Storage Policy showed that medications and biologicals used in the facility will be labeled in accordance with state and federal law as well as professional principles including the expiration date and multi-dose vials that have been opened will be dated upon opening and discarded within 28 days or by expiration date if within the 28 day window. Observation of the long-term care unit's medication storage refrigerator on 4/23/26 at 1:50P.M., showed an opened multi-use bottle of Lorazepam with no open date for one resident (Resident #45). During an interview on 4/23/26 at 1:50P.M., LPN C said that multi-use vials/bottles are good to use for 30 days after opening and that the bottles should be dated by staff upon opening Observation of the medication cart housed on the long-term care unit on 4/23/26 at 2:43P.M., showed:-Opened multi-dose bottle of Systane (a prescribed eye drop) with no open date, an opened multi-use bottle of Flonase (a nasal spray used to help with decongestion) with no open date and a multi-dose bottle of Refresh eye drops (used for dry eyes) with an open date of 03/11/2026 (Resident #6);-An opened multi-dose bottle of Debrox drops (used to assist with clogged ears) with no open date (Resident #21);-An opened multi-dose bottle of polyvinyl eye drops (used for dry eyes) with no open date (Resident #36);-An opened multi-dose bottle of deep-sea nasal spray (used for dry nasal passages) with no open date that was sent by the pharmacy on 09/24/25 (Resident #52). Observation of the medication cart used by nurses on the long-term unit on 4/24/26 at 1:45P.M., showed two opened, multi-use vials of glucose control solutions with no open date. During an interview on 4/23/26 at 2:445P.M., CMT A said that when opening a multi-dose vial or bottle, the medication or its packaging is labeled with the open date. During an interview on 4/24/26 at 9:40A.M., the Director of Nursing said that all medications and biologicals are to be dated upon opening and are good to use for 28 days after opening and should be discarded or destroyed if past the expiration date.

Based on observation, interviews, and record review, the facility failed to prevent pressure ulcers and provide necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing and affecting two residents (Resident #4 and Resident #3) out of 12 sampled residents. The facility census was 47. Review of the facility's undated Skin Care Protocol policy showed:-Facility clinical staff will ensure residents who enter the facility without a pressure sore(s) will not develop pressure sore(s) unless a resident's clinical condition demonstrates that the condition is unavoidable. - Upon admission all residents will have a Braden Pressure Risk Assessment (a widely used, evidence-based tool designed to predict a patient's risk of developing pressure injuries/sores) completed by nursing staff. A score of 18 or less indicates that a resident is at risk for skin breakdown. -Those residents determined to be at risk for skin issues will have interventions implemented. The policy did not state what types of interventions. 1. Review of Resident #4's Comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 04/10/26 showed:-Cognition impairment-Limited range of motion affecting one of his/her legs.-Dependent on staff for toileting, bathing and lower body dressing.-Maximum assistance to change positions in bed and transferring bed to chair.-Incontinent bowel and bladder.-Risk for pressure ulcers.-Diagnoses include Fracture of Right Femur, and Diabetes Mellitus During an interview on 04/22/26 at 09:26 A.M. the resident said:-He/she hadn't been changed and repositioned since last night at 9:00 P.M.-He/she had a new open sore on her buttocks-The sore burns with each incontinent episode-He/She upset that staff are not treating her wound and checking on him/her more. During an interview and observation of incontinent care on 04/22/26 at 10:09 A.M. showed:-CNA A was observed answering resident's call light. Resident said he/she was wet and that his/her bottom was burning and had not been changed since 9:00 p.m. the previous night. -CNA A applied gloves, began to provide incontinent care to perirectal area. Resident was positioned on his/her left side to facilitate a better view of buttocks.-Visualized a round dark purple colored softball sized pressure injury to coccyx area.-Visualized a round quarter size open area on the inner left buttocks. The area had yellow, wet dead tissue in the center with a beefy red outside edge. - An air foam mattress was in use and a low air loss mattress was leaning up against the wall.-CNA A completed incontinent care and placed barrier cream directly on the resident's open wound. Review of Physician's orders, dated April 2026 showed:-No order for wound care to her coccyx or buttocks. -No order to reposition every two hours and as needed.-No order for a low air loss mattress.-No orders for wound care interventions found. Review of admission nursing skin assessment 04/10/26 at 5:48 P.M. showed the resident had no open areas to coccyx or buttocks. Review of the care plan dated, 04/13/26 showed:-He/She had actual impairment to skin integrity on admission, 04/10/26, under both breasts and under abdominal fold. and a recent right hip surgical wound. -He/She was at risk for pressure ulcer development related to immobility, incontinence, and diagnoses.-Braden Score of 14/23, placing he/she at a moderate risk for pressure ulcers. Review of progress notes dated 04/21/26 at 01:55 P.M. showed a low air-loss mattress was provided to improve wound healing. Notes did not indicate if it was place on the resident's bed.Review of vital signs dated 04/22/26 showed resident's weight is 153.4 pounds.Observations of the resident on 04/23/26 at 9:30 A.M. showed resident laid flat on back in bed. Low air loss mattress leaning up against the wall and not in use.Observation of the resident on 04/23/26 at 12:15 P.M. showed he/she laid flat on back in bed. Low air loss mattress was still leaning up against the wall and not in use. Observation of the resident on 04/24/26 at 9:00 A.M. showed the resident was lying on his/her right side with the low air loss mattress in place and an air pressure setting set to the weight of a 350 pound person and not to the resident's actual weight. 2. Review of Resident #3's Comprehensive MDS 03/17/26 showed:-He/She had impairment on one side of lower extremities.-He/She required substantial to maximum assistance during bathing, toileting, and lower body dressing-Diagnoses include: fracture of right femur, and protein-calorie malnutrition Review of physician orders dated 04/23/26 9:23 A.M. showed: -Orders to apply offloading heel boots to both feet while in bed.-Orders to treat two chronic wounds to right foot including cleanse right ankle wound with wound cleanser pat dry with gauze cover with foam dressing daily and as needed if soiled and cleanse with wound right heel with wound cleanser pat dry with gauze apply skin prep to peri wound and cover with foam dressing daily and a needed.- An order dated 03/30/26 for a low air loss mattress.-No orders to treat coccyx wound.-No order to treat left heel.-No order to treat three surgical wounds on right hip and right thigh. Review of care plan dated 03/20/26 showed: -He/She had pressure areas and potential for pressure development related to immobility.-Impairment to skin integrity to both feet since admission care plan.-Had potential for skin integrity issues related to nutritional problems. Review of nursing progress notes dated 04/11/26 at 4:13 A.M showed:-He/She was admitted with wounds to bilateral heels, right buttocks, and mid back.-A new right ankle wound measuring 1.6cm x 1.12cm deep was indicated.-Had additional wound on right lateral ankle measuring .44cm wide x .53cm deep acquired on 04/03/26 after admission to the facility. Observations of the resident on 04/22/26 at 9:30 A.M. showed:-Resident sat in recliner in room without pressure relieving cushion to chair.-An air foam mattress was in place on his/her bed and the ordered low air loss mattress was not in place on the bed. Observations of the resident on 04/23/26 at 09:05 A.M. showed:-Resident laid in bed sitting at a 30 degree angle with head of bed elevated eating breakfast.-Low air loss mattress in place with a pressure setting set to 350 lbs for a resident who weighed 143 pounds without any offloading boots to feet. -Offloading boots were sitting in the corner on the floor. During an interview on 04/23/26 at 11:00 A.M. with CNA A said:-He/She should not have placed barrier cream on an open wound.-He/She tries to reposition residents that need it at least every 2 hours. -He/She would report a new wound to the charge nurse.-He/She would expect pressure relieving devices to be used when ordered. -He/She is notified by the charge nurse at the beginning of shift when pressure relieving devices are ordered. -Pressure relieving boots should be on when residents are in bed. During an interview on 04/23/26 at 02:30 P.M. with Registered Nurse A said:-He/She would expect new wounds to be reported to her by staff.-He/She would notify the DON, wound care nurse, and physician of new wounds.-He/She expects to receive a treatment order from the physician by the end of his/her shift today.-Pressure injury prevention begins at admission.-He/She expects offloading devices to be used as ordered.-He/She was unaware of new pressure injury concerns to Resident #4. It was her responsibility to check the pressure setting on the low air loss mattress every day. -He/She said the resident had refused to have the low air loss mattress when it arrived initially on 04/22/26, and that a late entry progress note was placed in the chart. - He/She would not expect a CNA to place barrier cream on an open wound. During an interview on 04/23/26 at 10:15 A.M. with DON (Director of Nursing) said:-She expects pressure injury prevention to start on admission. - It is the responsibility of nursing to ensure preventative measures and positioning devices are in place. -She would expect staff to report a new wound to her and the physician the same shift it is discovered.-She expected nurses to check the settings on a low air-loss mattress each shift and be set according to the resident's weight.-She would not expect a CNA to place barrier cream on an open wound. -She was unable to determine why there was a delay in treatment and monitoring. During an interview on 04/22/26 at 02:00 P.M. the Administrator said:-She expected prevention of pressure injury to begin on admission. -She was notified on 04/20/26 of Resident #4 coccyx wound.-She expects to be notified no later than at the next morning meeting of a new wound.-She expects the physician to be notified of a new wound the same shift with treatment orders obtained.

Based on observation, interview and record review, the facility failed to ensure the timeliness development and revision of each resident's person-centered, comprehensive care plan when the facility failed to add oxygen use and include a physician ordered hand splint and failed to update discharge planning after discharge plans changed for one resident( Resident #45); when the facility failed to ensure a care conference was held each quarter for two residents (Resident #34 & #5); when the facility failed to include respiratory status of a resident diagnosed with pneumonia (an infection in the lungs that makes breathing difficult) for one resident (Resident #34) and additionally when the facility failed to update the continence status and goals putting the resident at higher risk for complications for one resident (Resident #5). This affected three of 14 sampled residents. The facility census was 44.Review of the facility's Person-Centered, Comprehensive Care Plan Policy, dated 6/24/25, showed:-The Interdisciplinary Team (IDT) will collaborate with residents or representatives to plan individualized care, treatment and services;-The IDT is to include nursing staff, social services, dietary staff, activity staff, therapy as appropriate and other relevant personnel;-An initial care plan meeting to be held within 21 days of admission/re-admission;-The IDT and resident or representative will evaluate resident's care plan for possible revision of cares, treatments or services at 90-day intervals, or more frequently based on resident's condition;-Within seven days of the completion of the comprehensive assessment (MDS), the IDT will complete development of person-centered, comprehensive care plan;-The plan will include, but not is not limited to care, treatment, services, interventions which direct staff to meet the goals of each resident including frequency and what team members are responsible for proving care, treatment and services as well as discharge planning, either to community to another level of care or remaining in facility for long-term care;-Interventions will reflect each individual resident's needs;-The care plan may be amended any time the team determines it is necessary to ensure the resident receives appropriate care and services;-Each member of the IDT will perform assessments prior to the care plan conference and bring specific recommendations for the care plan;-IDT to monitor the implementation of the care plan;-Adherence is mandatory. 1.Review of Resident #45's Comprehensive Minimum Data Set (MDS), a federally mandated assessment performed by facility staff, dated 4/20/26, showed:-Severe cognitive impairment;-Resident dependent on staff for dressing, grooming and hygiene;-No respiratory infection, supplemental oxygen use or difficulty breathing indicated;-Diagnoses: Heart Failure, Non-Alzheimer's Dementia and aphasia (difficulty speaking). Review of the resident's care plan dated 2/2/26, showed:-He/She was at risk for skin breakdown and pressure injuries related to immobility;-No listed staff intervention to place or ensure placement of any splints or positioning aids;-No goals or interventions related to impaired breathing or supplemental oxygen use;-He/She had a terminal diagnosis and will receive hospice services at facility until end of life;-He/She would return to his/her prior living situation at an Assisted Living Facility. Review of the resident's POS (Physician Order Set) dated 4/24/26, showed a treatment order to apply a resting hand splint to Left hand for two hours during each day shift and two hours each night shift to decrease finger tone and promote better positioning and an order for supplemental oxygen via nasal cannula to maintain oxygen saturations and promote resident comfort. Review of the resident's electronic medical record (EMR) showed:-Resident had required supplemental oxygen via nasal cannula continuously since 4/21/26;-Nursing staff documented that ordered resting hand splint had been applied for two hours each shift from 4/1/26-4/20/26;-Resident was receiving daily hospice nursing visits from 4/20/26-4/24/26 related to decline in respiratory function, oral intake and mental status. During an interview on 4/22/26 at 9:10A.M., Certified Nurses Assistant (CNA) C said that each resident's care plan is accessible via EMR and that is how he/she knows how to care for each resident. During an interview on 4/23/26 at 1:45P.M., Licensed Practical Nurse (LPN) B said:-If oxygen is being administered to a resident, then that should be on the resident's care plan;-A resident diagnosed with heart failure often has shortness of air and requires supplemental oxygen;-Bedside nurses can add interventions to care plans such as when a resident falls or obtains a skin tear. During an interview on 4/24/26 at 9:40A.M., the Director of Nursing (DON) said:-Care plans are updated on a scheduled and as needed basis;-The care plan is meant to educate staff on how to care for each resident;-Resident #45 does not like the resting hand splint, it caused him/her increased pain and he/she often refused placement of splint;-If a resident has an order for oxygen or a resting hand splint, those should be on the resident's care plan so that staff can ensure implantation. During an interview on 4/24/26 at 11:00A.M., the Social Services Designee (SSD) said that care plan meetings are held every 90 days or as needed for changes in status and that it is not reasonable that a resident have a goal to discharge back to prior level as well as a goal to remain in facility until end of life. 2. Review of Resident #34's Comprehensive MDS dated [DATE], showed:-Resident taking a prescribed antibiotic during look back period;-No supplemental oxygen use;-Pneumonia (an infection in the lungs that makes breathing difficult) was not selected in the diagnosis portion;-Diagnoses included malnutrition, Non-Alzheimer's Dementia and atrial fibrillation (an irregular heart rate). Review of the resident's care plan dated 4/18/25, showed:-He/She has an altered cardiovascular status;-He/She was on an antibiotic for Pneumonia, initiated on 3/2/26;-No category, goals or interventions related to diagnosis of Pneumonia or respiratory status. During an interview on 4/24/26 at 10:25A.M., the MDS Nurse said that care plan meetings happen within two weeks of an MDS submission. During an interview on 4/24/26 at 11:00A.M., the SSD said that care plan meetings usually occur every 92 days. During an interview on 4/24/26 at 10:40A.M., the Assistant Director of Nursing (ADON) said that he/she initiates categories such as respiration and oxygen use on resident care plans after daily morning meetings but does not amend or remove items on care plans. During an interview on 4/24/26 at 9:40A.M., the DON said:-Care plans are updated on a scheduled and as needed basis;-The care plan is meant to educate staff on how to care for each resident;-Resident's that are diagnosed with respiratory infections such as Pneumonia often require additional services such as supplemental oxygen and increased monitoring to prevent decline in health or functional status and this should be documented and implemented in resident's individual care plan. 3.Review of Resident #5's Quarterly MDS, date 2/4/26, showed:-Severe cognitive impairment;-Maximum assist required with toileting, transfers and hygiene;-Occasional incontinence of bowel and bladder (defined as less than seven incontinence episodes during look-back period);-Diagnoses included cancer, high blood pressure and hip fracture. Review of the resident's care plan dated 10/15/25, showed:-Resident at risk for incontinence related to immobility and activity intolerance;-He/She has a communication problem;-Resident dependent on staff for activities of daily living such as toileting and bathing. Review of the resident's EMR on 4/21/26 showed no documented episodes of continence in a 30-day look back period. During an interview on 4/23/26 at 10:07A.M., CNA E said that CNA's document bowel and bladder function each shift. During an interview on 4/24/26 at 11:00A.M., the SSD said that care plan meetings usually occur every 92 days and it is not reasonable that a resident has a last documented care conference more than six months ago. During an interview on 4/24/26 at 9:40A.M., the Director of Nursing (DON) said:-Care plans are updated on a scheduled and as needed basis;-The care plan is meant to educate staff on how to care for each resident;-An incontinent resident should be care planned as incontinent, not as at risk for incontinence.

Based on observation, interview and record review the facility failed to treat residents with consideration, respect, and full recognition of their dignity and individuality when staff brought three sampled residents (Resident #40, #23 and #21) to meals in the dining room on three consecutive days with uncombed and disheveled hair, and when staff brought Resident #40 to a concert in the facility lobby with disheveled hair and stains on his/her shirt. This affected three of 12 sampled residents (Resident #40, #23 and #21 ). The facility census was 46. Review of the facility's undated Resident's Rights Policy showed:-Each resident residing at the facility has the right and will be afforded the right to a dignified existence, self determination;-The facility will ensure each resident has autonomy and choice;-The facility will promote the exercise of rights for each resident including residents who face barriers including all but not limited to, communication, hearing impairment and impaired cognition.Review of the facility's undated Right to Dignity Policy showed:-The facility will promote care for residents in a matter and an environment that maintains and enhances each resident's dignity and respect in full recognition of their individuality;-Residents will be groomed as they wish including hair care and styling;-Each resident will be provided dignity during all dining experiences;-Staff members will always exhibit respect for each residents wishes;-All staff will refrain from any practice that could be considered demeaning to a resident. 1. Review of Resident #40's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/21/26 showed:-Severe cognitive impairment;-Dependent on two staff for Activities of Daily Living (ADL)s;-Incontinent of bowel and bladder;-Diagnoses included dementia and arthritis. Review of the resident's care plan dated 03/26/26 showed:-ADL self care deficit related to dementia;-Impaired cognitive function;-Assistance of two staff for personal hygiene-Assistance of one staff for dressing and grooming.Observation and interview on 04/21/2026 at 11:35 A.M., showed:-The resident sat in a wheel chair;-Certified Nurses Aide (CNA) A pushed the resident out of his/her room;-CNA A pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA A said the resident's hair should be combed and clean and appropriate clothing should be worn;-CNA A did not offer to comb or assist the resident with grooming.Observation and interview on 04/22/2026 at 12:01 P.M., showed:-The resident sat in a wheel chair; -CNA B pushed the resident out of his/her room;-CNA B pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA B said the resident's hair should have been combed before the resident left his/her room;-CNA B did not know why the resident's hair was not combed;-CNA B did not offer to comb or assist the resident with grooming.Observation and interview on 04/22/2026 at 02:12 P.M., showed:-The Activity Director pushed the resident down the hall to the elevator in his/her wheel chair;-The Activity Director said he/she was taking the resident down to the lobby for a concert;-The resident had three white spots on the front of his/her shirt the size of golf balls;-The Activity Director pushed the resident in his/her wheel chair into the lobby for the concert;-Other residents sat in the lobby;-The Activity Director said time did not always allow for a change of clothes if the resident were to get to the activity on time;-The Activity Director said the resident's hair should be combed and the resident's clothes should be clean;-The Activity director said she had not realized that the resident had stains on his/her shirt.Observation on 04/23/2026 at 11:59 A.M., showed:-CNA A pushed the resident out of his/her room;-CNA A pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA A did not offer to comb or assist the resident with grooming. During an interview on 04/24/2026 at 7:47 A.M. the resident's family member said:-He/She expected the resident's hair to be clean and groomed;-He/She expected the resident's clothes to be clean when the resident went out of his/her room;-He/She expected the resident to be groomed and dressed in appropriately when the resident went to meals in the dining room and to activities 2.Review of Resident #23's Quarterly MDS, dated , 03/17/26 showed:-Severe cognitive impairment;-Dependent on one staff for ADLs;-Incontinent of bowel and bladder;-Diagnoses included dementia, cancer and coronary artery disease. Review of the resident's care plan dated 03/19/26 showed:-ADL self care deficit related to dementia and impaired mobility;-Impaired cognitive function;-Assistance of one staff for personal hygiene-Assistance of one staff for dressing.Observation and interview on 04/21/2026 at 11:45 A.M., showed:-CNA A pushed the resident out of his/her room;-CNA A pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA A said the resident needed help with personal hygiene;-CNA A said the resident's hair should be combed before he/she left the room;-CNA A did not offer to comb or assist the resident with grooming.Observation and interview on 04/22/2026 at 12:12 P.M., showed:-CNA B pushed the resident out of his/her room;-CNA B pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA B said the resident needed help with combing his/her hair;-CNA B said the staff helped with personal hygiene;-CNA B did not know why the resident's hair was not combed;-CNA B did not offer to comb or assist the resident with grooming.Observation on 04/23/2026 at 12:10 P.M., showed:-CNA A pushed the resident out of his/her room;-CNA A pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA A did not offer to comb or assist the resident with grooming.3. Review of Resident #21's Significant Change MDS, dated , 09/02/25 showed:-Severe cognitive impairment;-Dependent on staff for ADLs;-Incontinent of bowel and bladder;-Used oxygen;-Diagnoses included dementia, atrial fibrillation (irregular heartbeat) and deep vein thrombosis (blood clot forms in a deep vein).Review of the resident's care plan dated 03/02/26 showed:-ADL self care deficit related to impaired mobility;-Impaired cognitive function;-Total assistance of two staff for personal hygiene-Total assistance of two staff for dressing.Observation and interview on 04/21/2026 at 11:57 A.M., showed:-CNA A pushed the resident out of his/her room;-CNA A pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA A said the resident needed help with personal hygiene;-CNA A said the resident's hair should be combed before he/she left the room;-CNA A did not offer to comb or assist the resident with grooming.Observation and interview on 04/22/2026 at 12:25 P.M., showed:-CNA B pushed the resident out of his/her room;-CNA B pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA B said the resident needed help with combing his/her hair;-CNA B said the staff helped with personal hygiene;-CNA B did not know why the resident's hair was not combed;-CNA B did not offer to comb or assist the resident with grooming.Observation on 04/23/2026 at 12:28 P.M., showed:-CNA A pushed the resident out of his/her room;-CNA A pushed the resident down the hall and into the dining room;-Other residents sat in the dining room;-The resident's hair was uncombed and disheveled;-CNA A did not offer to comb or assist the resident with grooming.During an interview on 04/24/26 at 08:12 A.M., Licensed Practical Nurse (LPN) A said:-Residents #40, 2#3 and #21 had to have help with dressing and grooming;-It was the responsibility of the CNAs to make sure residents #40, #23 and #21 were groomed appropriately;-Nurses that notice a resident had not been groomed properly should instruct staff to take the resident back to the room and groom the resident;-All residents had the right to be groomed and feel good about how they look.During an interview on 04/24/26 at 08:56 A.M., the Director of Nursing (DON) said:-All residents should have their hair combed and be dressed in clean clothes;-She expected the nursing staff to make sure all residents were well groomed and dressed in clean clothes before going to meals or activities;-All staff should make sure residents are well groomed.During an interview on 04/24/26 at 08:59 A.M., the Administrator said:-She expected residents #40, #23 and #21 to have their hair combed and clean clothes on;-She expected all residents to be well groomed and dressed appropriately.

Based on observation, interview, and record review, the facility staff failed to follow professional standards of care according to clinical standards for two residents who were admitted as high risk for skin injury (Resident #4 and Resident #3); when the facility failed to obtain treatment orders and apply interventions to reduce risk for skin injuries; when they did not have preventative measures put into place to reduce skin injury; when the care plan was not updated to reflect the needs of these two residents and additionally when the facility failed to properly set-up, maintain and ensure correct functioning of specialty equipment used to reduce the risk of skin breakdown (Resident #5 and Resident #8). This affected four residents of the 12 sampled. The facility census was 44. Review of facility's undated Activities of daily living and skin care policies showed: -Skin barrier will be applied after each incontinent episode. -Pressure relieving devices will be used to relieve pressure. -Turn and reposition immobile residents approximately every 2 hours while in bed or wheelchair. -Residents who develop pressure sore(s) will receive necessary and appropriate treatment and services to promote healing, prevent infection, and prevent further development of additional impaired skin integrity. 1. Review of Resident #4's Comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 04/10/26 showed: -Cognition impairment -Limited range of motion affecting one of his/her legs. -Dependent on staff for toileting, bathing and lower body dressing. -Maximum assistance to change positions in bed and transferring bed to chair. -Incontinent bowel and bladder. -High risk for pressure ulcers. -Diagnoses: Fracture of Right Femur, and diabetes mellitus During an interview on 04/22/26 at 09:26 A.M. the resident said: -He/She hasn't been changed and repositioned since last night at 9:00 P.M: -He/She had a new open sore on buttocks; -His/Her bottom burns with each incontinent episode; -He/She feels upset that staff are not treating his/her bottom. During an Interview with resident and Observation of CNA A during incontinent care on 04/22/26 at 10:09 A.M. showed: -CNA A answered resident's call light. Resident said he/she was wet and that his/her bottom was burning and had not been changed since 9:00 p.m. the previous night. -CNA A applied gloves, began to provide incontinent care to perirectal area. Resident was positioned on his/her left side to facilitate a better view of buttocks. -Visualized a round, dark purple colored, softball sized pressure injury to coccyx (tail bone) area. -Visualized a round, quarter size open area on the inner left buttocks. The area had yellow, wet dead tissue in the center with a beefy red outside edge. - An air foam mattress was in use on the bed, and a low air loss mattress was leaning up against the wall. -CNA A completed incontinent care and placed barrier cream on resident's open wound. Review of Physician's orders, dated April 2026 showed: -No order for wound care to resident's coccyx or buttocks. -No order to reposition every two hours and as needed. -No order for a low air-loss mattress. -No orders for wound care interventions found. Review of the care plan dated 04/13/26 showed: -He/She had impairment to skin integrity on admission date 04/10/26 located under both breasts and under abdominal fold, and a recent right hip surgical wound. -The skin integrity care plan did not include the coccyx wound. -He/She was at risk for pressure ulcer development related to immobility, incontinence, and diagnoses. -The risk for pressure ulcer development was not addressed in the care plan and did not include which preventative measures staff needed to implement. -Review of skin risk assessment showed a score of 14, indicating he/she was a moderate risk for pressure ulcers and skin breakdown. Review of vital signs dated 04/22/26 showed resident's current weight is 153.4 pounds. Review of progress notes dated 04/21/26 at 01:55 P.M. showed a low air-loss mattress was provided to improve wound healing. Notes did not indicate if it was placed on the resident's bed. Review of admission nursing skin assessment 04/10/26 at 5:48 P.M. showed the resident had no open areas to coccyx or buttocks. Observations of the resident on 04/23/26 at 9:30 A.M. showed resident laid flat on back in bed. Low air loss mattress leaning up against the wall and not in use. Observation of the resident on 04/23/26 at 12:15 P.M. showed he/she laid flat on back in bed. Low air loss mattress was still leaning up against the wall and not in use. Observation of the resident on 04/24/26 at 9:00 A.M. showed the resident was lying on his/her right side with the low air loss mattress in place and an air pressure setting to the weight of a 350 pound person and not for a person with a weight of 150 pounds. 2. Review of Resident #3's Comprehensive MDS 03/17/26 showed: - He/She had impairment on one side of lower extremities. - He/She was dependent on staff during bathing, toileting, and lower body dressing. -Diagnoses: Fracture of right femur, and protein-calorie malnutrition Review of newly obtained physician orders, dated 04/23/26 9:23 A.M. showed: - Orders to apply offloading heel boots to both feet while in bed. - Orders to treat two chronic wounds to right foot including cleanse right ankle wound with wound cleanser pat dry with gauze cover with foam dressing daily and as needed if soiled and cleanse with wound right heel with wound cleanser pat dry with gauze apply skin prep to peri wound and cover with foam dressing daily and a needed. -An order dated 03/30/26 for a low air loss mattress. -No orders to treat coccyx wound. -No order to treat left heel. -No order to treat three surgical wounds on right hip and right thigh. Review of care plan dated 03/20/26 showed: -had pressure areas and potential for pressure development related to immobility. -had actual impairment to skin integrity to both feet since admission care plan. -has potential for skin integrity issues related to nutritional problems. -No care plan to address individualized pressure relieving interventions and devices. -No care plan to address the right ankle wound and right lateral ankle wound. Review of nursing progress notes dated 04/11/26 at 4:13 A.M showed: -He/She was admitted with wounds to bilateral heels, right buttocks, and mid back. -A new right ankle wound measuring 1.6cm x 1.12cm deep was indicated. -Had additional wound on right lateral ankle measuring .44cm wide x .53cm deep acquired on 04/03/26 after admission to the facility. No treatment orders were obtained. Observations of the resident on 04/22/26 at 9:30 A.M. showed: -Resident sat in recliner in room without pressure relieving cushion to chair. -An air foam mattress was in place on his/her bed, and the ordered low air loss mattress was not in place on the bed. Observations of the resident on 04/23/26 at 09:05 A.M. showed: -Resident in bed and sat at a 30-degree angle with head of bed elevated eating breakfast. -Low air loss mattress now in place with a pressure setting set to 350 pounds for a resident who weighed 143 pounds and no offloading boots to feet. -Offloading boots sat in the corner on the floor. During an interview on 04/23/26 at 11:00 A.M. with CNA A said: -He/She should not have placed barrier cream on an open wound. -He/She tries to reposition residents that need it at least every 2 hours. -He/She should have reported the new wound to the charge nurse. -He/She would expect pressure relieving devices to be used when ordered. -He/She is notified by the charge nurse at the beginning of shift when pressure relieving devices are ordered for resident's with new concerns. -Pressure relieving boots should be on when residents are in bed who have an order. During an interview on 04/23/26 at 02:30 P.M. Registered Nurse A said: -He/She would expect new wounds to be reported by the CNAs -He/She would notify the DON, wound care nurse, and physician of new wounds. -He/She will obtain a treatment order from the physician by the end of his/her shift today. -Pressure injury prevention begins at admission. -He/She expects offloading devices to be used as ordered. -He/She was unaware of new pressure injury concerns to Resident #4 until today. It was his/her responsibility to check the pressure setting on the low air loss mattress every day for anyone with orders for a low air loss mattress. -He/She said the resident had refused to have the low air loss mattress initially when it arrived initially on 04/22/26, and that a late entry progress note was placed in the chart regarding that. - He/She would not expect a CNA to place barrier cream on an open wound. During an interview on 04/23/26 at 10:15 A.M. with DON (Director of Nursing) said: -She expects pressure injury prevention to start on admission. - It is the responsibility of nursing to ensure preventative measures are in place. -She would expect staff to report a new wound to her and the physician the same shift it is discovered and obtain treatment orders. -She expected nurses to check the settings on a low air-loss mattress each shift and correlate with the resident's current weight. -She would not expect a CNA to place barrier cream on an open wound. -She was unable to determine why there was a delay in treatment and monitoring. During an interview on 04/24/26 at 10:45 A. M. the MDS Coordinator said: -She reviews wound care notes weekly on Monday. -She is notified by the DON or ADON of new wounds. -All wounds should be care planned. -She would look for a wound care order when care planning a new wound. -If there was no order for treatment, she would notify the DON. -She was unaware of any new wounds. During an interview on 04/22/26 at 02:00 P.M. the administrator said: -She expects prevention of pressure injury to begin on admission. -She was notified on 04/20/26 of Resident #4 coccyx wound. -She expects to be notified no later than at the next morning meeting of a new wound. -She expects the physician to be notified of a new wound the same shift. Review of Instruction Manual for Airemed Alternating Pressure Low Air Loss Mattress showed: -Setting the weight on a low air loss mattress ensures proper immersion and envelopment, which prevents pressure sores; -The mattress must be adjusted to hold the user's weight to ensure air cells properly inflate and deflate, reducing pressure on bony areas; -Correct weight settings help the mattress maintain a floating effect, which allows the mattress to keep the skin cool and reduce sweat and moisture build up. 3. Review of Resident #5's Quarterly MDS dated [DATE], showed: -Resident had severe cognitive impairment; -He/She dependent on staff for transfers, toileting and grooming; -Diagnoses included malnutrition, cancer and Alzheimer's Dementia. Review of the resident's care plan dated 10/15/25, showed: -He/She had the potential for pressure injury (bedsore) development related to immobility and activity intolerance; -Staff to identify and document potential causative factors of skin breakdown and eliminate where possible; -He/She was incontinent of bladder and required nursing staff to assist with cares and hygiene; -A Low-Air Loss Mattress (LALM) or specialty pressure reducing mattress was not listed as an intervention. Review of the resident's electronic medical record dated 4/2/26, showed that resident weighed 96.7 pounds. Review of the resident's physician orders dated 4/21/26, showed no physician order for a LALM pressure reducing specialty mattress. Observation on 4/21/26 at 10:20A.M. showed resident lying in bed on LALM that had an air pressure setting for a person that weighs 300 pounds. Observation on 4/22/26 at 1:03P.M., showed the resident's LALM remained set at 300 pounds. Observation on 4/23/26 at 8:05A.M., showed the resident's LALM remained set at 300 pounds. 4.Review of Resident #8's Quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -He/She had significant weight loss; -Diagnoses included malnutrition, diabetes and Non-Alzheimer's Dementia. Review of the resident's care plan, dated 9/17/25, showed: -He/She had potential for pressure ulcer development related to immobility; -He/She is at risk for slow-healing wounds related to vascular disease; -He/She required assistance from facility staff for hygiene, toileting and walking; -A Low-Air Loss Mattress (LALM) or specialty pressure reducing mattress was not listed as an intervention. Review of the resident's electronic medical record dated 4/2/26, showed resident's weight of 106 pounds. Review of the resident's physician orders dated 4/21/26, showed no physician order for a LALM or specialty mattress. Observation on 4/21/26 at 10:24A.M., showed resident's LALM was set for a person who weighed 215 pounds. Observation on 4/22/26 at 8:04A.M., showed resident's LALM remained set at 215 pounds. Observation on 4/23/26 at 8:14A.M., showed resident's LALM remained set at 215 pounds. During an interview on 4/24/26 at 9:20A.M., LPN A said: -A physician order is required for a low air loss mattress; -The equipment delivery service is responsible for placement of LALM on resident's bed; -Sometimes facility maintenance staff applies and sets up specialty beds; -He/She does not know if anyone is checking each LALM for proper use and maintenance; -He/She knows that LALM are to assist with prevention of skin breakdown and pressure injuries; -He/She had not had any education or in-services regarding LALM placement, maintenance and care; -He/She would like to have more education and information on LALM since he/she cares for several residents that have LALM; -If a LALM is not set a the residents actual weight this can increase pressure and cause skin breakdown. During an interview on 4/24/26 at 9:40A.M., the DON said: -A physician order is required for placement of specialty beds or mattresses; -Specialty mattresses should be on the resident's care plan as an intervention to assist with the prevention of skin breakdown; -A mattress that was set up incorrectly can cause too much pressure on the resident or, if under inflated, resident could be lying or sitting on metal bed frame; -It is not reasonable for a resident with a weight of 100 pounds to have his/her LALM set at 300 pounds; -Facility staff will be receiving education on proper set up and care of specialty mattresses.

Based on observation, interview and record review, the facility failed to ensure that each resident received an accurate assessment, reflective of the resident's status when the facility submitted an assessment with inaccurate information on how resident expelled urine from the body (Resident #8). This affected how the care plan was developed and implemented for one of 12 sampled residents. The facility census was 44.Review of the facility's Accuracy and Transmission of The Minimum Data Set Policy dated 12/2025, showed:-The Minimum Data Set (MDS) serves as a vital role in the development of the care plan of every resident;-The Interdisciplinary Team (IDT) will work together to ensure the information is documented accurately, reflecting the true needs of the resident;-It is the responsibility of the MDS Coordinator to ensure the MDS is completed accurately, timely and successfully transmitted. 1.Review of Resident #8's Quarterly MDS, a federally mandated assessment completed by facility staff, dated 3/25/26, showed:-Severe cognitive impairment;-He/She had a nephrostomy tube (a thin, flexible tube surgically inserted through residents back and into the kidney to bypass urinary tract blockages);-His/Her urinary continence was not rated as resident had a catheter or no urine output for entire seven-day look-back period;-Diagnoses included kidney disease, high blood pressure and Non-Alzheimer's Dementia. Review of the resident's care plan, dated 9/17/25, showed:-He/She required assistance from nursing staff for toileting, grooming and personal hygiene;-Nursing staff to assist resident with care of nephrostomy tube;-His/Her nephrostomy tube was placed during hospitalization related to recurrent infections and obstructive uropathy (structural or functional blockage of urine flow). Review of the resident's electronic medical record (EMR) dated 4/24/26, showed:-Nursing documentation that the resident had daily urine output for previous 30 days;-A physician order dated 11/4/25 for nursing staff to ensure resident is offered assistance to the restroom every 2 hours;-A progress note dated 3/20/26 written by the facility's MDS Coordinator that said clarification had to be obtained related to inconsistent nursing documentation. During an interview on 4/21/26 at 1:20P.M., CNA F said that he/she is required to chart urine and bowel output on each resident each shift. During an interview on 4/24/26 at 10:25A.M., the MDS Coordinator said:-A nephrostomy tube is not the same as an indwelling catheter (a flexible tube placed in the bladder to drain urine);-People can still urinate even with a nephrostomy tube;-Resident #8 still does produce urine and his/her MDS should not say that he/she had no urine output for seven days;-He/She obtained information from resident's EMR as well as resident and staff interviews. During an interview on 4/24/26 at 9:40A.M., the Director of Nursing said:-Each resident should have nursing documentation of any output each shift;-A nephrostomy tube does not stop a resident from producing and eliminating urine;-It is not reasonable for a resident to have no nursing staff charting in their EMR in a seven-day period.

Based on interview and record review, the facility failed to prevent an avoidable medication error which resulted in the hospitalization of one resident (Resident #1) when facility staff administered insulin to a resident who was not a diabetic. The resident was admitted to the hospital with a diagnosis of hypoglycemia (low blood sugar; a direct effect of insulin administration) and received D10 (intravenous fluids with added dextrose). The resident was diagnosed with acute metabolic encephalopathy (a reversible brain dysfunction caused by a metabolic imbalance or toxicity) due to accidental insulin administration. This affected one resident out of two sampled. The facility census was 47. Review of the facility's undated Medication Administration policy showed:-All medication passes will follow accepted practice-Rights of Medication Administration including administering medication to the right person;-Each resident will be free from unnecessary drugs, defined as: without indications for use. 1.Review of Resident #1's Quarterly Minimum Data Set, (MDS, a federally mandated assessment tool completed by facility staff) dated 2/11/26, showed:-Severe cognitive impairment;-Maximum assistance needed with sit to stand task;-Resident was non-ambulatory;-Resident received scheduled pain medication;-Diagnoses included Non-Alzheimer's Dementia, traumatic brain injury, and heart disease. Review of the resident's care plan, dated 2/25/26, showed:-Resident had the potential for pressure ulcer development related to immobility;-Resident was a high risk of falls related to deconditioning, gait/balance problems;-Staff to ensure call light was within reach and encourage resident to use;-No documented staff interventions regarding diabetes management or care. Review of the resident's nursing progress note, dated 02/06/2026 at 8:13P.M., showed:-At 6:47P.M., Licensed Practical Nurse (LPN) A assisted Certified Nurse's Assistant (CNA) L with putting resident to bed;-CNA A was told by CNA B that the resident they were assisting to bed was Resident #2;-CNA B went into resident's room to verify that it was Resident #2 and CNA B confirmed that the resident was Resident #2;-LPN A assessed resident's blood glucose by performing a finger stick procedure with a reading of 142 and administered 20 units of Insulin Glargine, a long-acting insulin;-LPN A then went to verify identity of Resident #1 with Certified Medication Technician (CMT) and it was discovered that the residents had been placed in the wrong beds and LPN administered insulin to the wrong resident;-LPN A notified the residents physician, facility staff, and family per facility protocol and the physician instructed to send the resident to the hospital if blood sugar dropped below 110.-The resident was sent to the hospital at 7:40 P.M. for monitoring of blood sugar levels when blood sugar reading dropped to 104 , IV fluids, and evaluation by physician. Review of the resident's progress note, dated 02/07/2026 at 1:49A.M., showed that the resident was admitted to the hospital with a diagnosis of hypoglycemia (low blood sugar; a direct effect of insulin administration). Review of the hospital physician's history and physical of the resident, dated 02/06/2026, showed:-The resident was placed on D10 IV fluids (intravenous fluids with added dextrose);-The resident was diagnosed with acute metabolic encephalopathy (a reversible brain dysfunction caused by a metabolic imbalance or toxicity) due to accidental insulin administration. Review of facility's undated Medication Error investigation showed:-LPN A verified resident identity with 2 CNAs;-CNA A reported that CNA B confirmed identity of Resident #2 several times;-CNA B was not sure of the identity of the resident he/she confirmed identity of;-LPN A was advised to ask the resident and other staff members to verify resident identity;-LPN A was not allowed to work at facility again. During an interview on 02/27/2026 at 1:45P.M., LPN A stated:-He/She attempted to confirm resident's identity with two staff members as well as the resident;-The resident was unable to identify self;-The resident was identified as Resident #2 by CNA A and CNA B prior to medication administration;-He/She used the CNA's tablet to better visualize the resident's picture in the electronic medical record and compare to the resident in the bed; -No residents on the unit wear identifying arm bands;-After discovery of medication error, all parties were notified and orders followed. During an interview on 2/27/2026 at 3:10 P.M., DON stated:-If resident is not able to confirm own identity, staff are to ask another staff member to verify;-Resident pictures are updated on as needed basis, no policy or procedure regarding updating of resident pictures on EMR (Electronic Medical Record). During an interview on 03/03/2026 at 8:15A.M., the Administrator stated:-There is no facility policy on how often and who is to update resident pictures in electronic charting system;-There are no names on doors unless resident chooses to place their own;-Resident #1 was placed in Resident #2's bed after CNA A confirmed identity of resident with CNA B. Intake 2737751

Based on observation, interview and record review, the facility failed to safely transfer one of two sampled residents (Resident #1) when staff were not aware the resident required transfer with a mechanical lift and a staff member transferred the resident with a gait belt. This affected one resident out of two sampled. The facility census was 47. Review of the facility's undated Safe Lift, Transfer and Repositioning Policy showed:-Manual lifting of any and all residents who are unable to bear weight will be limited to use of mechanical lift;-Residents identified as totally dependent or extensive assistance will be transferred by means of mechanical lift with the aid of a full body sling rather than by manual lift/assist;-The comprehensive Nursing assessment and MDS section G will be the primary nursing assessment tools for determination of each resident's need for assistance and transfer activities;-The care plan will be reviewed and revised on a continual basis;-The administrator is responsible to facilitate and ensure in-services and training is timely and complete with documentation of all training;-Nursing Supervisors are to ensure all residents, including new and those with change of condition, are assessed for appropriate lift and transfer assistance;-Direct staff are responsible to use proper techniques during resident handling tasks;-Notify supervisor of resident change in condition which might necessitate a re-evaluation of the resident and lift use;-If the resident's mobility or ability to assist varies throughout the course of the day or day to day, the varied ability will be noted in their care plan;-The determination of which lift to use will be documented in resident's care plan; The facility's undated Mechanical Lift Transfer Policy showed: residents who are unable to bear any weight will be transferred safely with a mechanical lift (a device used to support the body weight of a resident during transfers). Review of the facility's undated Use of Transfer Belt/Gait Belt policy showed:-Ensure the resident has appropriate footwear and their feet are on the floor prior to transferring;-Stand in front of the resident;-Position one hand on either side of the gait belt with underhand grip and assist resident to move forward until their feet are touching the floor; -For a pivot transfer, place one hand on each side of the buckle;-Assist the resident to a standing position;-When activity complete, return resident to place of their choice and assist them to a comfortable, safe position. Review of Resident #1's Quarterly Minimum Data Set, (MDS, a federally mandated assessment tool completed by facility staff) dated 2/11/26, showed:-Severe cognitive impairment;-Maximum assistance needed with sit to stand task;-Resident non-ambulatory;-Resident received scheduled pain medication;-Diagnoses included Non-Alzheimer's Dementia, traumatic brain injury and heart disease. Review of the resident's care plan dated 2/25/26, showed:-Resident had potential for pressure ulcer development related to immobility;-Resident was a high risk of falls related to deconditioning, gait/balance problems;-Staff to ensure call light within reach and encourage resident to use;-No documented staff interventions on how to transfer resident. Observation of Resident #1 during a transfer on 02/26/2026 at 7:55 P.M., showed:-Certified Nursing Assistant (CNA) D applied gait belt by sliding it down the back of resident's head and along his/her spine. -CNA C looped his/her right arm through resident's right arm and grabbed gait belt with left hand, behind resident's back. CNA D looped his/her left arm through resident's left arm and grabbed gait belt at patients back with right hand. CNA D did a countdown from three, CNA C and CNA D lifted the resident and pivoted him/her onto the edge of the bed, during the transfer, CNA D stumbled kicked the wheelchair, propelling it backwards, causing CNA D to set the resident on bed with excessive force; -Resident moaned during transfer;-Resident was not asked to scoot forward, nor was his/her feet on the floor.-The resident was not transferred in a safe manner and not accordingly to the facility's safe lift and transfer policy. During an observation and interview on 02/27/2026 at 2:30P.M., CNA D said:-Transfer statuses of residents are on the 24-hour report sheet and that it should always be correct;-He/She is unaware of who updates the transfer statuses of residents;-He/She believed Resident #1 was a one-person transfer, but for safety reasons, he/she prefers to use two people to transferring Resident #1;-During a transfer, if a resident can bear weight, his/her feet should touch the ground. -CNA D was unaware that mechanical lift was already in the resident's room or that hospice staff had provided the equipment for the resident for staff to utilize. During an interview on 2/27/2026 at 3:10P.M., DON said:-Transfer statuses of all residents are in their EMR and are easily accessible by all nursing staff;-The Interdisciplinary Team updates resident's transfer statuses and changes are documented/updated as needed;-If a resident is unable to bear weight in legs, he/she should be transferred with a mechanical lift;-During a stand pivot transfer, the resident's feet should remain on ground;-Staff should not loop his/her arms into resident's arms and lift at armpit level; During an interview on 03/03/2026 at 8:15A.M., the Administrator said:-A resident that is listed as a two-person transfer should be able to bear weight on his/her feet and his/her feet should touch the ground during transfer;-Staff should not lift residents by the arms;-Residents that are totally dependent on staff to lift them during transfer should be transferred with a mechanical lift;-Transfer and mobility status changes should be updated in the resident's care plan so staff know what type of transfer is needed. Intake 2737751

Based on interview and record review, facility staff failed to follow facility policy by not securing one resident's (Resident #1) controlled substance (substances with high probability for physical and/or psychological dependence), resulting in the loss of the controlled substance. The facility census was 44.On 12/2/25, the Administrator was notified of the past noncompliance incident which occurred on 10/27/2025. On 10/28/25, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented to include: Replacement of the medication and education of all licensed staff regarding signing in and securing delivery of narcotic mediation. The noncompliance was corrected on 11/5/2025.Review of the facility's undated Medication Administration Policy showed all medications will be administered to every resident as ordered by a physician in a safe and sanitary manner. Review of the facility's undated Documenting Administration of Controlled Substance policy showed:-It is the responsibility of the Nurse and/or Certified Medication Technician (CMT) administering a controlled substance to follow the appropriate policy to ensure proper documentation and count of controlled substances;-Check in order to ensure the right resident, right drug, right dose, right route, and right time;-Pull the medication from the card and sign the medication out on the controlled drug record;-Take medication to the resident and administer the medication staying with the resident to ensure the resident takes the medication prior to leaving the room;-Immediately chart the medication was given in the Electronic Medical Record (EMR), chart appropriately, signing out on the controlled substance sheet alone does not meet the procedure of this medication pass;-It must be charted in the EMR to ensure there is proper and appropriate documentation in the EMR;-At the beginning and end of each shift the staff will complete the following: Count each number of medications on each card and liquids by milliliters for accuracy and sign off. Review of the facility's undated Controlled Medication Check In policy showed:-When the pharmacy delivers a controlled medication, the nurse accepting the medication will review delivery sheet for the list of controlled medications and verify quantity of medication on the card;-If medications are present and correct count, check mark next to medication, sign delivery sheet, copy delivery sheet and give one to pharmacy and one to medical records, write the count on the quantity received on the count sheet/date/and sign, put count sheet into the narcotic count binder, put medication directly into the locked box on the nurses med cart;-If the medication is not present, indicate that on the delivery sheet, sign the delivery sheet for other medications, copy delivery sheet and give one to the pharmacy and one to medical records, call pharmacy and inform them it wasn't delivered, note in the resident's chart it wasn't received;-It is the responsibility of the nurse on duty to ensure the procedure is followed, controlled medications are handled appropriately, and medications are accounted for;-If there is a discrepancy, please notify the Director of Nursing (DON) and/or Administrator immediately. 1. Review of Resident #1's electronic medical record on 12/2/25 showed:-The resident's diagnoses included: Fracture of right femur, osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), pain, reduced mobility, falls, obesity (abnormal or excessive fat accumulation that presents a risk to health), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen throughout the body). Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 10/19/2025, showed:-The resident had adequate hearing, clear speech, makes self understood and understands others;-He/She scored 9 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents);-This score indicated moderately impaired cognition;-He/She received scheduled and as needed pain medication;-He/She reported frequent pain. Review of the resident's comprehensive care plan, dated 10/14/25, showed interventions related to high risk for falls, nutrition, pain related to right hip fracture with repair, and need for assistance with activities of daily living (ADLs). Review of the resident's pain care plan dated, 9/4/25 showed: -The resident received pain medication for chronic pain;-The staff were supposed to anticipate the resident's pain needs and respond to any complaints of pain. Review of the facility investigation on 12/2/2025, showed:-On 10/28/25, Registered Nurse (RN) A advised the DON Resident #1 had a missing card and narcotic count sheet for oxycodone (a highly addictive pain medication used to manage severe pain);-RN A attempted to pull and give Resident #1 an as needed dose of medication, but none was available;-RN A called the pharmacy and was advised that a card of 18 tablets of oxycodone 5 Milligrams (MG) was delivered to the facility on [DATE] and signed for by Licensed Practical Nurse (LPN) A;-The pharmacy and the facility administrator were notified of the missing medications;-The physician was notified of the missing medications and provided a new prescription and the facility provided for replacement medications;-Camera footage from the night of 10/27/25 into 10/28/25 was reviewed by facility administration but no information was gathered;-All medication carts and medication lock boxes were searched but the missing medication was not recovered;-LPN A was suspended pending investigation;-All nurses working at the time the medication was noted missing (RN A, LPN A, and LPN B) were drug tested for narcotic medications, and all tested negative;-All nurses and certified medication technicians (CMTs) were in-serviced about signing in and administration of narcotic medication;-LPN A received education and returned to work at the facility on 11/6/2025. Review of the resident's October 2025 physician orders showed an order for oxycodone 5MG, give one tablet by mouth every four hours as needed for pain. Review of the pharmacy delivery sheet dated 10/27/25 showed one card of 18 tablets of oxycodone 5MG was delivered for the resident on 10/27/25 and signed for by LPN A. Review of RN A's statement dated 10/29/25, showed:-The resident asked for a pain pill the afternoon of 10/28/25;-RN A looked in the medication cart and the card of medication was not there;-RN A had worked on ordering some of the oxycodone on 10/27/25 as the resident had taken the last pill in that card;-RN A looked in the medication safe and the medication was not there;-RN A then called the pharmacy, who advised the medication was delivered to the facility the night of 10/27/25 and signed for by the night nurse, LPN A;-RN A searched the nurse medication cart, CMT medication cart and the other's nurses medication cart and the missing card of medication was not located;-RN A reported the missing medication to the DON. Review of LPN B's statement dated 10/29/2025, showed:-LPN B worked the night of 10/27/25 on the opposite hall of LPN A;-When the pharmacy arrived and delivered the medications, LPN A signed for all the medications and gave LPN B the medications for his/her hall;-LPN B took the medications and secured them in the medication cart for his/her hall. During an interview on 12/2/25 at 10:45 A.M., the DON said:-It was his/her expectation staff follow the facility policy and appropriately sign in and secure narcotic medication when delivered by the pharmacy; -The resident's medication were quickly replaced and the resident did not go without pain medication. During an interview on 12/2/25 at 1:29 P.M., the Administrator said it is his/her expectation that all licensed staff sign in and secure narcotic medication per facility policy when delivered by pharmacy. Intake 2655980

Based on interview and record review the facility failed to ensure that one resident (Resident #1) received treatment and quality of care in accordance with professional standards of practice when Licensed Practical Nurse (LPN) A transcribed Resident #2's medications into Resident #1's Medication Administration Record (MAR) in error, which resulted in Resident #1 receiving 42 doses of the wrong medications and Resident #1 being admitted to the hospital with increased heart rate and low blood pressure. The facility census was 41.Review of the facility's undated Physician Orders for Medications and Treatments policy showed all medications will be administered as ordered by a healthcare professional.Review of the facility's undated Medication Administration Policy showed all medications will be administered to every resident in a safe manner.Review of the facility's undated Resident [NAME] of Rights policy showed:-The resident had the right to follow their physician's advice and instructions;-The resident had right to maintain a safe home environment.Review of the job description for the charge nurse, dated November 2021, included to be able to prepare, administer and document medications per the physician's order and accurately record all care provided.Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 06/15/25 showed:-Moderate cognitive impairment;-Extensive assistance of one staff for activities of daily living (ADLs);-Diagnosis included Congestive Heart Failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs), high blood pressure and osteoarthritis. Review of the resident's care plan dated 7/10/25 showed:-Impaired cognitive function related to pain;-Requires extensive assistance with activities of ADLs;-Resident will receive medications as ordered. Review of the resident's admission Checklist dated, 8/22/25 showed:-Duties to be completed by the admitting nurse included, find/add the resident in the Electronic Medical Record (EMR), add medication orders to the EMR and fax the mediation order to the pharmacy;-LPN A was the admitting nurse;-LPN A documented he/she had added the resident's medication orders to the EMR;-Duties to be completed by the following shift nurse included double check the resident's orders for accuracy;-There was no documentation indicating LPN C had double checked the resident's orders for accuracy.Review of the Resident #1's physician's order sheet (POS) dated August 2025, showed medications for Resident #2:- Apixaban (used to prevent blood clots) 2.5 milligrams (mg) twice daily;- Citalopram (used to treat depression) 20 mg daily;- Cyanocobalamin (vitamin B12 supplement) 2000 micrograms (mcg)s daily;- Dronedarone (used to treat abnormal heart beat) 400 mg daily;- Ferrous Sulfate (iron supplement) 325 mg daily;- Levothyroxine (used to treat low thyroid levels) 50 mcg daily;- Melatonin (used for sleep) 10 mg daily;- Metoprolol (used to treat high blood pressure) 25 mg daily;- Olanzapine (used to treat mental health disorders) 10 mg give daily;- Omeprazole (used to treat acid reflux) 20 mg daily;- Rosuvastatin 20 mg daily;- Sennosides-docusate (stool softener) twice daily;- Januvia (used to lower blood sugar) 10 mg daily.Review of Resident #1's Medication Administration Record (MAR) dated August 2025, showed 42 doses of medication had been given in error:-08/22/25 Apixaban 2.5 mg P.M. dose, Olanzapine 10 mg, Januvia 100 mg, Melatonin 10 mg, Rosuvastatin 20 mg, Omeprazole 20 mg, Metoprolol 25 mg, Sennosides-docusate P.M. dose;-08/23/25 Citalopram 20 mg, Ferrous Sulfate 325 mg, Januvia 100 mg, Levothyroxine 50 mcg; Melatonin 10 mg, Metoprolol 25, Omeprazole 20 mg, Apixaban 2.5 mg A.M. and P.M. doses, Dronedarone 400 mg, Olanzapine 10 mg, Sennosides-docusate A.M. and P.M. dose, Cyanocobalamin 2000 mcg, Rosuvastatin 20 mg;-08/24/25 Ferrous Sulfate 325 mg, Cyanocobalamin 2000 mcg, Metoprolol 25 mg. Januvia 100 mg, Levothyroxine 50 mcg, Melatonin 10 mg, Apixaban 2.5 mg A.M. and P.M. doses, Omeprazole 20 mg, Olanzapine 10 mg, Sennosides-docusate A.M. and P.M. doses, Dronedarone 400 mg, Rosuvastatin 20 mg;-08/25/25 Ferrous Sulfate 325 mg, Levothyroxine 50 mcg, Sennosides-docusate A.M. dose, Januvia 100 mg, Cyanocobalamin 2000 mcg.During an interview on 8/26/25 at 11:18 A.M. family member A said:-The Resident #1 was readmitted to the facility from the hospital on Friday 8/22/25;-On Monday 8/25/25 he/she was notified the resident had received multiple doses of another resident's medication in error and the physician had been notified;-On Monday 8/25/25 the facility informed him/her the resident complained of dizziness;-The resident's blood pressure was low with an increased heart rate and the physician had given orders to send the resident to the hospital;-The resident is still at the hospital and stable.During an interview on 8/26/25 at 11:52 A.M. the nurse caring for Resident #1 at the hospital said:-The resident was admitted through the emergency department on 8/25/25 for low blood pressure and increased heart rate;-The resident had received double doses of blood pressure lowing medications and a doses of a medication that treats heart rhythm in error at the facility;-The resident was very sleepy and the resident's blood pressure is still below normal;-The resident will not be returning to the facility until his/her blood pressure closer to normal.2. Review of Resident #2's admission MDS dated [DATE] showed:-Mild cognitive impairment;-Supervision for ADLs;-Diagnosis included atrial fibrillation (a heart rhythm disorder), high blood pressure and diabetes. Review of the resident's care plan dated 8/26/25 showed:-Impaired cognitive function related to dementia;-Received medications that have black box warnings; (a warning alerting healthcare providers of serious risks, including potentially fatal side effects).Review of the resident's discharge orders from the hospital dated 8/21/25, showed:- Apixaban 2.5 mg twice daily;- Citalopram 20 mg daily;- Cyanocobalamin mcg daily;- Dronedarone 400 mg daily;- Ferrous Sulfate 325 mg daily;- Levothyroxine 50 mcg daily;- Melatonin 10 mg daily;- Metoprolol 25 mg daily;- Olanzapine 10 mg give daily;- Omeprazole 20 mg daily;- Rosuvastatin 20 mg daily;- Sennosides-docusate twice daily;- Januvia 10 mg daily.During an interview on 8/26/25 at 12:38 P.M., Nurse Practitioner A said:-She was notified on 8/25/25 after the MDS nurse discovered Resident #1 received serval doses of the wrong mediations;-The MDS nurse said he/she discovered Resident #2's medications were transcribed into Resident #1's EMR;-She gave new orders to discontinue the wrong medications and monitor resident #1 closely;-She expected LPN A to transcribe resident #1's order correctly into the EMR;-She expected the facility to have a working system in place to prevent this from happening again;-She expected all residents at the facility to receive the correct medication.During an interview on 8/26/25 at 12:50 P.M., the MDS nurse said:-On 8/25/25 she audited Resident #1's chart and the medications did not match the hospital discharge orders;-She informed the administrator and realized Resident #2's medications were on Resident #1's medication list;-Resident #1 was admitted on a Friday evening and she did not audit Resident #1's chart until Monday 8/25/25;-Resident #1 had been given the wrong medication all weekend;-She expected the day and night shift nurses to do the initial audits;-She audited new admission when she was here during the week;-Resident #1 should not have received the wrong medications.During an interview on 8/27/25 at 09:34 A.M., LPN A said:-He/She readmitted Resident #1 from the hospital on the evening of 8/22/25;-At around 4:30 P.M., he/she got slammed with three admissions at the same time;-He/She had medication to pass and insulin to administer in addition to the new admissions; -A chart audit for Resident #2 was placed on top of Resident #1's admission paperwork;-He/She transcribed Resident #2's medication orders into Resident #1's EMR in error;-He/She reached out to the Director of Nursing (DON)for help with the workload;-The DON told LPN A to get a new nurse from the other nursing hall;-LPN A said he/she did not have time to get a new nurse and explain everything that needed to be done;-LPN C came on shift after LPN A and did not double check Resident #1's medication orders for accuracy;-There error was not caught until several doses of the wrong medications had been given to Resident #1;-The error was not discovered until 8/25/25;-LPN A sent resident #1 out to the hospital on 8/25/25 for complaints of dizziness, increased heart rate and low blood pressure;-He/She had complained to the DON and Administrator about the work load being heavy and about night shift LPN C not double checking the medication orders for accuracy after new admissions;-If he/she had not been so busy the error might not have happened;-Resident #1 should not have received Resident #'2 medications.During an interview on 8/27/25 at 10:10 A.M., LPN B said:-He/She was working on the other side of the rehab hall when resident #1 was admitted ;-The evening Resident #1 was admitted , three other admissions arrived at the same time and it was extra busy;-LPN A told LPN B the DON said to get another nurse to help;-No other nurse came to help LPN A;-The nurse from the next shift is expected to double check new resident medication orders for accuracy;-Sometimes it did not get done on the night shift and the day shift had to do the audit when they came back in the next morning;-Resident #2's audit paperwork was mixed in with Resident #1's admission paper because the night shift did not do the audit;-There is a check off sheet with duties that each shift nurse completes when admissions come;-It is the duty of the night shift nurse to double check medication orders for all new admissions;-During the week the MDS nurse will does a triple check for all new admits;-Resident #1 was admitted on a Friday evening;-The MDS nurse only worked during the week;-The MDS nurse found the error on Resident #1's medications on a Monday;-The admitting nurse should try to double check the medications after they are transcribed;-The Certified Mediation Technicians (CMT) would not have known the wrong medications were on resident #1's MAR;-The admitting nurse is responsible for putting in resident orders correctly.During an interview on 8/27/25 at 11:32 A.M., LPN C said:-He/She has worked at the facility for six months;-Resident #1 was admitted on the day shift;-He/She knew the resident's medications had already been put in the system;-He/She did not double check Resident #1's medications for accuracy;-He/She said she did not complete the night shift nurse check off admission check off list because the admission was not completed yet;-He/She should have double checked resident 1#'s orders;-Resident #1 should not have received the wrong medications.During an interview on 8/27/25 at 12:12 P.M. the Assistant Director of Nursing (ADON) said:-LPN C should have double checked Resident #1's medications for accuracy;-The facility had a three-step system for double checking medications on new admissions;-The admitting nurse should have checked his/her work, then the nurse that comes in on the next shift should double check the medications and the third step is the when the MDS nurse audits the new admission and tripled checks the medications;-The facility system failed because the MDS nurse is only here on weekdays and this happened during the weekend;-The are no plans at the this time to have someone here on the weekends to do a triple check on the new admission medications;-LPN A should have entered the correct medications in to resident1 #'s EMR;-LPN C, the night shift nurse, should have doubled checked them;-The Resident #1 was sent the hospital on 8/25/25 for low blood pressure and increased heart rate.During an interview on 8/30/25 at 1:00 P.M. the DON said:-LPN A transcribed Resident #2's medications into resident #1's EMR;-LPN A should have slowed down and ensured the correct medications were entered;-LPN C was the night shift nurse that came in on the shift after LPN A;-LPN C should have double checked the new orders for accuracy;-The MDS nurse does a medication audit of all new admissions;-Resident #1 was admitted on a Friday evening and the MDS nurse did not do an audit until the following Monday:-Resident #1 received several doses of the wrong medication;-Resident #1 was sent to the hospital on 8/25/25 for low blood pressure and increased heart rate;-Resident #1 should have received the correct medications.During an interview on 8/27/25 at 1:12 P.M., the Manager said:-The procedure for the night nurse to double check the medications for resident #1 was not followed by LPN C;-She expected LPN A have entered resident #1's admitting orders correctly;-The MDS nurse does an medication audit of all new admissions;-Resident #1 was admitted on a Friday evening and the MDS nurse did not do an audit until the following Monday;-There are no plans at this time to have someone on the weekends to do a triple check on new admissions;-Resident #1 should not have serval doses of the wrong medications.During an interview on 9/11/25 at 4:15 P.M., the Administrator concurred with the Manger. Intake 2599227

Based on observation, interview and record review, the facility failed to respect one resident's rights, when the facility performed Cardiopulmonary Resuscitation on Resident #1, when he/she had a signed Do Not Resuscitate order. This deficient practice affected one of four sampled residents. The facility census was 54. Review of the facility's, undated, Resident Rights Policy showed:- Each resident residing in the facility has the right and will be afforded the right to a dignified existence and self determination;-Each resident will have autonomy and choice to the maximum extent possible;-Resident rights include the right to request, refuse and/or discontinue treatment; -The right to end of life care that respect and follows the resident's stated goals and choices for care and service at the end of the resident's life.Review of Resident #1's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) showed: -Some cognitive loss; -Need for partial assistance with Activities of Daily Living (ADLs: tasks completed in a day to care for oneself). -Diagnoses of atrial fibrillation (Afib: irregular and sometimes rapid heart beat) hypertension, and chronic kidney disease.Review of the resident's comprehensive care plan dated [DATE] showed: Code status of DNR, honor his/her wishes.Review of the resident's physician order sheet for [DATE] showed: Code status: DNR (Do Not Resuscitate).Review of the resident's nurse progress notes showed:-[DATE] at 2:40 P.M. The resident was working with therapy, the resident complained of having no energy or strength. The resident slumped over and did not respond. The resident was placed on the floor and CPR was started. The Director of Nursing (DON) called Emergency Medical Services and the resident's family. DNR paperwork was found, CPR continued until EMS arrived at 3:05 P.M. and called time of death. At 4:56 P.M. an area funeral home was on site to pick up the resident.During an interview on [DATE] at 12:47 P.M. Licensed Practical Nurse (LPN) B said: -DNR paperwork was kept in a book at the nurses station; -DNR direction is also found in the resident's electronic medical record; -A picture of a butterfly or a heart should have been on the back of every resident door; -The butterfly signifies DNR and the heart signifies to perform CPR.During an interview on [DATE] at 1:00 P.M. Registered Nurse B said: -DNR paperwork was kept in a book at the nurses station;-The DNR book should be checked immediately when a resident is nonresponsive; -A picture of a butterfly or a heart could be found on the back of every resident door; -The butterfly signified DNR and the heart signified to perform CPR;During an interview on [DATE] at 1:22 P.M. Registered Nurse (RN) A said: -He/She was the charge nurse for Resident #1 on [DATE]; -About 2:45 P.M. the resident was working with Therapy on toilet transfers and had complained he/she was too weak. RN A went to the room to assist with the transfer; -Resident #1 complained of weakness and right arm weakness; -Resident #1 slumped to the left side, was nonresponsive and his/her color was completely white; the resident was moved to lie on the floor. RN A checked the back of the resident's room door, found no butterfly or heart picture, and started CPR; -He/She told staff to get help; -When help arrived it was the DON, who had the DNR paperwork for the resident; -When EMS arrived they pronounced the resident deceased . During an interview on [DATE] at 1:59 P.M. Resident #1's Nurse Practitioner said: -Staff should not have performed CPR; The resident had a DNR; -The resident did not want CPR and staff should have followed his/her wishes; -He/She would expect staff to follow the resident's wishes for no CPR.During an interview on [DATE] at 10:04 A.M. the Director of Nursing said: -He/She would expect staff to check the electronic medical record first, and the DNR book prior to initiating CPR; -Signs in the residents rooms should not be the only indicator to begin or not begin CPR; -He/She would expect staff to honor the resident's wishes.Incident 1783011

Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date the receipt of incoming products in the dry storeroom, label and date used products in the freezer and refrigerator, label and date leftovers in the refrigerator, discard expired leftovers, and monitor refrigerator, freezer and dishwasher temperatures on a daily basis. This had the potential to impact all residents by placing them at risk for food born illnesses. The facility census was 40. Review of the facility's policy Dietary Procedures, undated, showed the evening staff members will check the dates on containers of leftovers and dispose of food found to have been refrigerated for more than four days; A policy on temperature checks in the kitchen was requested and not provided; Observation at 9:00 A.M on [DATE] showed: Dry Kitchen Storage Room located on the 1st floor: - Box of pancake mix opened and no opening date written on package; - Seven loose juice cocktail containers sitting out of case package with no date written; - Thickened Orange Juice opened box with no date written; Refrigerator 1st Floor: - Two plastic bags of tortillas opened and not dated; - Raw strawberries in plastic container not dated; - Leftover chicken soup in facility plastic container not dated; - Multiple containers of pudding and yogurt not dated; - Pulpy unknown food in bag dated ,d+[DATE] (57 days old); - Raw pickles, Jalapenos, green peppers, onions and squash bagged and undated; - Romaine lettuce dated ,d+[DATE] (6 days old) not discarded; - Sharp cheese open bad not sealed, not dated; - Opened hot dogs bagged, no date or label; - Seven unknown condiments stored in facility plastic bottles no dates, not labeled; - Open Jello container not dated; Observation at 9:35 A.M. on [DATE] showed: Main Kitchen Dry Storeroom Ground Floor - No received dates on multiple unopened packages of cake mixes and double chocolate cake; - Eight bags of chocolate chip cookie mix undated; - Four rack levels of unopened bread with no received date; - Extra heavy mayonnaise plastic container not dated; - Opened caramel topping Smuckers brand not dated; Freezer - Chicken patties opened and not sealed with no date; - Frozen peas opened box with no date; - Fillets not labeled and not dated; - Dry noodles unsealed and not dated; - [NAME] Spunkmeyer cookie dough opened and uncovered; - Review of dishwashing log shows no temperatures taken on the dishwasher from ,d+[DATE] to ,d+[DATE] (morning); Observation at 10:02 on [DATE] showed: Main Prep Area Kitchen Ground Floor - Refrigerator and Freezer temperature log missing temperature checks from ,d+[DATE] to ,d+[DATE] - Refrigerator/Freezer checks for ,d+[DATE] already entered into the log one day early; Refrigerator Ground Floor - Swiss cheese repackaged undated in a soiled bag; - Sauce unlabeled in facility container with no date; - Lettuce rewrapped with unreadable date on package; - Large unlabeled container of lettuce no date; Interview conducted on [DATE] at 9:20 A.M., [NAME] A said: -He has one and a half years' experience working at the facility. - The purpose of the refrigerator on the 1st floor kitchen area is to hold ingredients for cooking. - Policy directs staff to date opened products in bags and containers and store in the refrigerator for later use. - The date on the package is the first use date when opened. - He believes the policy is that after three days any item not used should be discarded. Interview conducted on [DATE] at 9:25 A.M., [NAME] B said the reason for all of the undated items in the refrigerator is that with the dishwasher down they have not had time to review the contents of the refrigerator on a daily basis. In an interview on [DATE] at 2:33 P.M., DM A said: - The leftover policy is ,d+[DATE] days which is mostly for vegetables. - All items need to be labeled and dated with first use date. - Incoming shipments need to have items annotated with receipt date, opened cases need date of when they were opened and expiration is in accordance with the item label. - The staff are to follow milk expiration dates on the package. - Condiments in jugs need to be discarded after 30 days and condiments in facility serving bottles need to be discarded after seven days. - Open items should be labeled and dated. - Temperature logs and dishwasher logs need to be done daily. In an interview on [DATE] at 1:30 P.M., RD (Registered Dietician)said the expectation is that leftovers are labeled and dated. Beef could be kept for three to four days and everything else is expected to be discarded sooner than that. Bags with no labels and no dates would be annotated on his/her inspection report for the facility staff to take action. In an interview on [DATE] at 10:20 A.M., Administrator said she would expect temperature logs to be maintained daily in the kitchen and leftovers to be sealed, labeled and dated.

Based on observation, interview, and record review the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected four of 12 sampled residents, (Resident #18, #27, #22 and #14). The facility census was 40. Review of the facility's undated Perineal Care Protocol Policy showed: -Perineal care is very important in maintaining the resident's comfort and should be completed after each incontinent episode; -Provide privacy; -Perform hand hygiene; -Separate all skin folds and cleanse all perineal areas; -Turn resident to the side and wash perineal area buttocks cleaning all areas; -Reposition the resident; -Perform hand hygiene. Review of the facility's undated policy for indwelling catheter protocol, showed: - Procedure for care of an indwelling urinary catheter: - Clean the perineal area and catheter tubing proximal to distal, with warm, soapy water or a disposable cleansing wipe followed by rinsing the area twice daily and after every bowel movement; - Retract the skin fold and the area washed thoroughly, rinse well and replace the skin fold 1. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/24, showed: - Severe cognitive impairment; - Dependent on staff for activities of daily living (ADLs); - Frequently incontinent of bowel and bladder; - Diagnoses included: Alzheimer's disease, aphasia (disorder that makes it difficult to communicate), and high blood pressure. A review of the resident's care plan dated 12/2/24 showed: - The resident has an ADL self care performance deficit related to limited mobility; -The resident is dependent on staff for personal hygiene and toileting. Observation on 12/12/24 at 08:37 A.M., showed: -The resident in bed; - Certified Nurses Aide (CNA) A and CNA D removed the resident's brief; - CNA A washed hands and applied clean gloves and used one wipe to clean under the resident's abdominal fold; -CNA A used one wipe to clean down the left groin and a different wipe to clean down right groin; -CNA A used a wipe and wiped down the front of the resident and did not spread the skin and clean all areas that urine or feces had touched; -CNA A and CNA D turned the resident on his/her side and CNA D used a wipe and cleaned the back of the resident; -CNA D did not clean all areas that urine or feces had touched; -CNA A and CNA D washed hands and applied clean gloves and placed a clean brief on the resident; -CNA A and CNA D failed to provide complete perineal care to the resident when they did not spread the skin and clean all areas that urine or feces had touched. During an interview on 12/12/24 at 9:05 A.M., CNA A said: -A different wipe should be used for each cleansing motion when doing peri care; -All areas that urine or feces have touched need to be cleaned; -Staff should spread and clean all areas and skin folds that urine or feces have touched. During an interview on 12/12/24 at 9:09 A.M., CNA D said: -One wipe one swipe is how peri care should be completed; -Staff should spread the skin to clean the front and make sure they clean all areas of the back that urine or feces came in contact with. 2. Review of Resident #27's Quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Substantial assistance from staff for ADLs; - Always incontinent of bowel and bladder; - Diagnoses included: Alzheimer's disease, depression and anxiety. A review of the resident's care plan dated 11/22/24 showed: -The resident requires extensive assistance with ADLs; -The resident has bladder incontinence related to Alzheimer's disease. Observation on 12/12/24 at 10:45 A.M., showed: - Registered Nurse (RN) A and CNA F transferred the resident to the toilet and removed the resident's brief; - CNA F washed hands and applied clean gloves and cleaned the backside of the resident; - CNA F washed hands and applied clean gloves and cleaned under the resident's abdominal fold and left and right groin, using a new wipe for each cleansing; -CNA F cleaned the front of the resident and did not spread the skin and clean all the areas that urine or feces had touched; - CNA F and RN A washed hands and applied clean gloves and put a clean brief on the resident; -CNA F did not provide complete perineal care to the resident when he/she did not spread the skin and clean all areas that urine or feces had touched. During an interview on 12/12/24 at 10:52 A.M., CNA F said staff should spread and clean all areas and skin folds that urine or feces have touched. During an interview on 12/12/24 at 10:59 A.M., RN A said: - A new wipe should be used each time staff clean; - Staff should spread and clean all areas and skin folds that urine or feces have touched. During an interview on 12/13/24 at 10:52 A.M. the Director of Nursing (DON) said: -He/she expects staff to separate skin folds and cleanse all areas that urine or feces have touched; -Staff should not use the same area of the wipe to clean different areas of the skin; -He/she expects staff to use one wipe per one swipe. During an interview on 12/13/24 at 10:52 A.M. the Administrator concurred with the DON. 31102 3.Review of Resident' #22's Quarterly MDS, dated [DATE] showed:- Long and short term memory problems; - Lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene and transfers; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - Diagnoses included obstructive uropathy ( a condition in which the flow of urine is blocked), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), progressive neurological disorder (condition where there is a progressive deterioration in functioning), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and dementia (inability to think). Review of the resident's care plan, revised 10/22/24 showed: - The resident required enhanced barrier precaution (EBP, gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO, multi-drug resistant organisms, resistant to one or more classes of antibiotics), as well as those at increased risk of MDRO acquisition). [NAME] and doff gloves and gowns during high-contact cares. Perform proper hand hygiene. Use biohazard trash receptacles for disposal of EBP refuse; - The resident is on antibiotic therapy related to a urinary tract infection (UTI, an infection in any part of the urinary system). Administer medication as ordered; - The resident has an indwelling catheter related to obstructive uropathy. Provide catheter care as needed; - The resident required extensive assistance with activities of daily living (ADL). Extensive assistance of one staff for dressing. Extensive assistance of two staff for toilet use. Dependent on the assistance of two staff for transfers; - The resident is at risk for bladder incontinence related to Alzheimer's disease. The resident used disposable briefs and staff should change as needed. Check the resident every two hours and as required for incontinent care. Review of the resident's urinalysis (UA, a test to analyze urine contents), dated 11/29/24, showed the presence of bacteria indicative of a possible urinary tract infection (UTI). Review of the resident's urine culture and sensitivity (UA with C & S, identifies the amount and type of bacteria present and the medications appropriate to treat the infection), dated 12/2/24, showed the presence of organisms indicative of a possible UTI. Review of the resident's medication administration record, (MAR) dated December 2024, showed an order for Cefdinir dated 12/2/2024 for 300 milligrams (mg) one capsule twice daily for seven days for UTI. Observation on 12/12/24 at 7:09 A.M., showed: - CNA E entered the res room, did not don a gown or wash his/her hands and applied gloves; - LPN A entered the resident's room with the mechanical lift, did not don a gown or wash his/her hands and applied gloves; - CNA E unfastened the resident's brief; - CNA E did not anchor the catheter tubing and used the same area of the wipe and wiped down the catheter tubing; - CNA E did not separate and clean all the skin folds; - CNA E and LPN A turned the resident on his/her side; - CNA E cleaned the buttocks and applied a house barrier cream to the resident's buttocks and placed a clean incontinent brief under him/her; - CNA E removed his/her gloves, did not wash his/her hands and applied gloves; - LPN A And CNA E turned the resident side to side and removed the wet incontinent brief and placed a clean incontinent brief under him/her; - LPN A removed his/her gloves and did not wash his/her hands; - CNA E removed gloves, did not wash his/her hands and applied gloves; - CNA E placed the graduate (a graduated cylinder or container used to collect and measure urine) in a gray basin, unclamped the drainage bag and emptied 250 milliliters (mls.) of urine into the toilet; - CNA E did not clean the port before or after emptying the urine; - CNA E removed gloves and did not wash his/her hands; - CNA E and LPN A used the mechanical lift and transferred the resident from his/her bed to the broda chair (a type of reclining geri-chair); - CNA E washed the resident's face and hands and combed his/her hair; - CNA E did not offer or provide oral care; - LPN A and CNA E washed their hands. During an interview on 12/12/24 at 2:39 P.M., CNA E said: - The catheter tubing should be anchored close to the insertion cite; - The port of the drainage bag should be cleaned with an alcohol wipe; - Should separate and clean all areas of the skin folds; - Should not use the same area of the wipe to clean different areas of the skin; - Should wear a gown and gloves with a resident who had a wound or a catheter; - If you can't wash your hands, should sanitize when you enter the resident's room and between glove changes. Should wash your hands before you leave the room. During an interview on 12/12/24 at 2:57 P.M., LPN A said: - Should separate and clean all areas of the skin where urine or feces had touched; - Should not use the same area of the wipe to clean different areas of the skin; - Should sanitize your hands when you enter the resident's room. Wash your hands after you're done with cares. He/she thought you should wash your hands after sanitizing your hands. Should wash your hands or sanitize between glove changes and before you leave the room. During an interview on 12/13/24 at 10:52 A.M., the DON said: - When staff get the resident up in the morning, the staff should brush the resident's teeth or offer oral care, make sure their hair is brushed or combed, offer hearing aides; - Staff should separate and clean all the skin folds and staff should not use the same area of the wipe to clean different areas of the skin. 47195 51626 4. Review of Resident #14's undated Care Plan showed: -Staff were expected to maintain the resident's dignity at the highest level. -The resident required extensive assistance with activities of daily living (ADLs). -The resident required one - two staff members assistance with toileting. -Resident had bladder and bowel incontinence related to dementia, parkinson's disease, and impaired mobility and wore disposable briefs. -Staff were expected to check and change the resident every two hours. -Staff were expected to wash and dry the resident's perineal area with each incontinent episode. Observation of Resident #14's peri care performed by CMT B and CNA A on 12/11/24 at 10:31 A.M. showed: -After removing the resident's soiled brief, staff used a wet wipe to clean a across the resident's pubic bone and down the center of the genitals. Staff failed to clean the skin folds on either side of the genitals. -After running out of gloves, CNA A left the room to get more. -While cleaning the resident's bottom, CNA A's gloves became soiled with fecal matter along the outer side of his/her left pinky finger. CNA A failed to remove the soiled gloves and/or complete hand hygiene. During an interview on 12/13/24 at 10:52 A.M., the Administrator and the Director of Nursing (DON) both agreed and said: -Staff are expected to separate and clean skin folds during peri care. -Staff are expected to complete hand hygiene before and after all resident cares.

Based on observation, interview, and record review, the facility failed to ensure staff used proper techniques when transferring four of the 12 sampled residents, ( Resident #18, #27, #28, and #14) during the use of a mechanical lift, and additionally during the use of a gait belt transfer for resident #28. The facility census was 40. Review of the facility's undated Use of Transfer Gait Belt policy showed: - Gait belts will be used when transferring residents who are partially dependent and have some weight bearing capacity; - Explain the procedure to the resident and place the gate belt around the resident's waist; - Ensure the belt is securely fastened and cannot be easily undone; - Staff members need to position one hand on either side of the gate belt with underhand grip and assist the resident forward. Review of the facility's undated Transfer and Repositioning policy showed: - It is the policy of the facility to provide safe and appropriate transfers of residents as to prevent injuries; -All personnel are responsible for implementing this policy; -Resident handling and movement tasks will be carried out in accordance with comprehensive nursing and the individualized care plans; -Lifting equipment will be operated in accordance with manufactures instructions; -Mechanical devices require two staff at all times. Review of the manufactures instructions for the sit to stand mechanical lift dated 2/16/16, showed: -Transfer from the wheel chair: -Push mechanical lift toward the resident; -Open the base of the lift to go around the chair; -Apply the brakes in both rear castors; -Position the resident; -Release the brakes, close the legs of the lift and transfer resident; -Reverse the above procedure when lowering the resident to bed or chair. Review of the undated manufacturer's guidelines for the mechanical lift showed: - Do not lift a resident with the caster brakes on. Always let the lift find the correct center of gravity; - Never perform a lift/transfer with the legs in the closed /transport position (front casters touching); - When lifting, the casters should be left free and un-braked, so that the lift will then be able to move to the center of gravity of the lift. Do not apply the brakes unless parking the lift. 1. Review of Resident #18's Quarterly Minimum Data Set (MDS), A federally mandated assessment instrument completed by facility staff, dated 11/26/24, showed: - Severe cognitive impairment; - Dependent on staff for activities of daily living (ADLs); - Diagnoses included Alzheimer's disease, aphasia (disorder that makes it difficult to communicate), and high blood pressure. A review of the resident's care plan dated 12/2/24 showed: - The resident has an ADL self care performance deficit related to limited mobility; - The resident is dependent on staff for transfers; -The resident is dependent on staff for personal hygiene and toileting. Observation on 12/12/24 at 08:37 A.M., showed: -The resident was in bed; -Certified Nurses Aide (CNA) A brought the mechanical lift into the resident's room; -CNA A pushed the lift to the resident's bed; -The legs of the lift were not spread and the breaks remained unlocked; -CNA A and CNA D hooked the resident up to the sling pad; -CNA A used the control and raised the resident off the bed; -CNA D left the resident and went into the bathroom while CNA A was at the head of the lift opposite the resident; -The resident was suspended in the lift with no staff stabilizing him/her; -The resident was swinging back and forth in the lift; -The staff failed to safely stabilize the resident while he/she was suspended in the lift. During an interview on 12/12/24 at 9:05 A.M., CNA A said: -There should be two nursing staff using the lift at all times; -One staff member operates the controls of the lift and the other stabilizes the resident as they are raised by the lift and while being transferred. -He/She should have stabilized the resident the entire time the resident was up in the lift. During an interview on 12/12/24 at 9:09 A.M., CNA D said: -It takes two staff to use the mechanical lift lift; -One staff runs the control and one staff stabilizes the resident; -He/she should not have left the resident unsupported in the lift. During an interview on 12/12/24 at, 10:43 A.M., Licensed Practical Nurse (LPN) A said when a resident is suspended in the mechanical lift, staff should be stabilizing the resident by guiding the resident in the sling along with the lift. 2. Review of Resident #27's Quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Substantial assistance from staff for mobility and transfers - Diagnoses included: Alzheimer's disease, depression and anxiety. Review of the resident's care plan dated 11/22/24 showed: -The resident requires extensive assistance with ADLs; - The resident requires extensive assistance with transfers; -The resident has bladder incontinence related to Alzheimer's disease. Observation on 12/12/24 at 10:45 A.M., showed: -The resident was in his/her room in a wheelchair; -CNA F locked both brakes of the resident's wheel chair; -CNA F brought the sit-to-stand mechanical lift into the resident's room; -CNA F spread the legs of the lift around the resident's wheel chair and locked the brake of the left rear [NAME]; -The right rear [NAME] remained unlocked; -Registered Nurse (RN) A and CNA F hooked the resident up to the lift pad; -CNA F raised the resident up in the lift and unlocked the left rear [NAME]; -CNA F and RN A transferred the resident to the bathroom; -RN A locked the right rear [NAME] on the lift; -The left rear [NAME] remained unlocked; -RN A lowered the resident to the toilet; -CNA F provided peri care; -CNA F and RN A hooked the resident back up to the lift; -RN A unlocked the right rear [NAME]; -The resident was moved back to the living room to his/her wheel chair; -RN A spread the legs of the lift and lowered the resident to the wheel chair; -RN A left both brakes of the rear castors unlocked while lowering the resident to the wheel chair; -CNA F and RN A unhooked the resident from the lift pad. During an interview on 12/12/24 at 10:52 A.M., CNA F said: -The only time time the brakes are to be locked is when the lift is parked; -He/she did not realize he/she only left one of the rear brakes unlocked; -Staff should leave the brakes of the lift unlocked while raising or lowering the resident. During an interview on 12/12/24 at 10:59 A.M., RN A said: -The brakes should be locked on the lift when raising or lowering a resident; -He/she did not realized he/she had only locked one break on the lift. 3. Review of Resident #28's Quarterly MDS dated [DATE], showed: - Moderate cognitive impairment. - Required substantial assistance from staff with dressing and toileting; - Diagnoses included Parkinson 's Disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns), high blood pressure, anxiety and depression. Review of the resident's care plan dated 9/20/24 showed: - The resident requires extensive ADL assistance; - The resident is at risk for falls related to Parkinson 's Disease. Observation on 12/13/24 at 8:45 A.M., showed: -The resident was in his/room setting in a wheelchair; -CNA C locked the wheelchair and placed the gait belt around the resident's waist; -CMT D and CNA A stood on each side of the wheelchair; -CNA C grabbed the front of the gait belt with his/her left hand and hooked his/her right arm under the residents left arm; -CMT D grabbed the front of the gait belt with his/her right hand and hooked his/her left arm under the residents right arm; -CNA A and CMT D lifted the resident and transferred him/her to the bed; -CNA A and CMT D failed to do a safe gait belt transfer when they hooked their arms under the resident's arms instead of grabbing the back of the residents gait belt. During an interview on 12/13/24 at 9:32 A.M., CMT D said he/she should have grabbed the back of the resident's gait belt instead of hooking the resident under his/her arm during the transfer. During an interview on 12/13/24 at 9:40 A.M., CNA C said he/she should have grabbed the back of the resident's gait belt instead of hooking the reisdent under his/her arm during the transfer. During an interview on 12/13/24 9:53 A.M., LPN A said: - The gate belt should be placed around the resident's waist; - Staff should grab the gait belt and not the resident when doing a gait belt transfer; - Staff should never grab or put their arm under the resident's shoulder to transfer. During an interview on 12/13/24 at 10:52 A.M. the Director of Nursing (DON) said: -He/she expects staff to have two hands on the gait belt; -No staff should be lifting underneath the arms of the resident; -He/she expects the manufactures guidelines to be followed when using a mechanical lift; -He/she expects the brakes to be unlocked while a resident is in the lift; -He/she would expect staff to ensure they are stabilizing the resident who is up in the lift. During an interview on 12/13/24 at 10:52 A.M. the Administrator concurred with the DON. 47195 51626 4. Review of Resident #14's Medical Record showed: -Resident required extensive assistance from two staff members with all transfers. Staff are to use the mechanical lift for transfers due to the resident's recent decline. -The resident is receiving hospice services due to end-stage Parkinson's disease (a disorder of the nervous system that affects movement and worsens over time). -The resident's diagnoses include Unspecified Dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) Generalized Muscle Weakness -The resident is at risk for falls due to deconditioning, It is the goal of the resident/resident's representative and the facility, that the resident remains free of falls. Observation on 12/11/24 at 10:31 A.M. showed: -Mechanical lift transfer of Resident #14 from his/her wheelchair chair to the bed, performed by CMT B and CNA A. The residents bottom was hanging partially over the edge of the sling 's edge and the top edge of the sling was well above the resident's head, forcing his/her chin against his/her chest. This improper sling placement left the resident vulnerable to falling from the sling while in the air. -Staff did not correctly position the resident in the sling prior to raising the sling with the mechanical lift. The resident's arms dangled from either side of the sling, leaving the resident vulnerable to potential impact injury during transfer. During an interview following the transfer on 12/11/24 at 10:31 A.M., CNA A said he/she realized the resident was improperly placed in the sling but they had already begun moving the mechanical lift to the bed and he/she thought it was just better to get him/her there quick. During an interview on 12/13/24 at 10:52 A.M., the Director of Nursing (DON) and Administrator agreed: -Staff are expected to follow manufacturer guidelines when using mechanical lifts. -When staff use a mechanical lift to lift a resident in a sling, the staff are expected to position the resident correctly in the sling and keep the resident stable during the transfer.

Based on interview, and record review, the facility failed to provide services that met professional standards of quality when staff failed to recognize and report significant weight loss and/or gain. This affected four of the 12 sampled residents (Resident #28, Resident #295, Resident #244, and Resident #294). Facility census was 40. The facility's policy for Monitoring Weights stated: -All residents will be evaluated for weight stabilization and timely identification of weight loss. -Significant weight loss will be defined as: 3% loss in one week, 5% loss in 30 days, 7.5% loss in 90 days, and/or 10% loss in 180 days. -The physician, resident, and/or legal representative will be notified immediately (within 24 hours) of any resident meeting the definition of significant weight loss in this policy and informed on the interventions implemented. -Any resident with significant weight loss will be referred to the Registered Dietician Nutritionist (RDN) for recommendations. -The recommendations of the RDN will be communicated to the resident's primary care physician and family upon receipt of the recommendations. - The policy does not address significant weight gain. The facility's Role of Registered Dietician policy showed the Registered Dietician (RD) will be notified of weight changes weekly either in person, by phone conference, or by fax with a specific request for individualized recommendations. The facility's Preventive Maintenance and Inspection policy stated: -Resident weight scales will be calibrated by a licensed outside contractor quarterly and as needed due to use, wear, and tear. -The facility did not provide the requested scale calibration/inspection logs. 1. Review of Resident # 28's undated Care Plan showed: - The resident requires extensive assistance from staff for most activities of daily living (ADLs) including toileting and transfers. - The resident has a diagnosis of Diabetes. Staff are expected to monitor for signs and symptoms of hyperglycemia (elevated blood sugar), one of which is weight loss. - The resident is taking an antibiotic, which puts him/her at risk for experiencing anorexia (a lack of interest in food and/or eating). Staff are expected to monitor for side effects of this medication every shift. - The resident has a nutritional problem related to moderate malnutrition, diabetes, and Parkinson's disease. Staff are expected to monitor/record/report to the doctor (MD), signs and symptoms of malnutrition, including significant weight loss. - The resident is at risk for dehydration or potential fluid deficit related to diuretic use. Staff are expected to monitor/record/report to the MD, signs and symptoms of dehydration, including recent/sudden weight loss. Review of Resident #28's medical record showed: - On 11/04/24, Resident #28 weighed 173.1 lbs. - On 11/20/24, he/she weighed 142.0 lbs. This calculated to a loss of 31.1 lbs., or 18% in 16 days. - On 11/24/24, Resident #28 weighed 136.2 lbs. This calculated to a loss of another 5.8 lbs., or 4.1% in four days. - On 11/25/24, Resident #28 weighed 139.0 lbs. - On 12/02/24, Resident #28 weighed 138.6 lbs. - On 12/09/24, Resident #28 weighed 137.6 lbs. - In total, Resident #28 lost 35.5 lbs. between 11/04/24 and 12/09/24, or 20.5% in 35 days. - The percentage of weight lost was calculated by the facility's electronic medical record program and the resulting calculation was visible to staff reviewing the resident's weights. - No documentation of notification made to Resident #28's Primary Care Provider related to significant weight loss. - No documentation of notification made to the RD related to specific request for individualized recommendations. 2. Review of Resident #295's Care Plan, revised 12/04/24 showed: - The Resident had a diagnosis of Diabetes and staff are expected to monitor for signs and symptoms of hyperglycemia (elevated blood sugar), one of which is weight loss. - He/She has a potential for nutritional problems related to immobility due to fractures/pain. Staff are expected to monitor/report to the doctor (MD) as needed, signs and symptoms of malnutrition, including significant weight loss. - Is taking two antidepressant medications, Venlafaxine and Mirtazapine. Staff are expected to monitor/document/report to the MD, signs and symptoms of on going depression unaltered by the prescribed medications, which include changes in weight. Review of Resident #295's December Physician Orders showed: - Order Date: 12/04/24, Monitor for side effects, adverse reactions, and behaviors related to antidepressants, anxiolytics (anti-anxiety medications), hypnotic (sleeping medication), and psychotropic medications (medications used for some mental health conditions). Notify Practitioner of and chart any adverse reaction, side effect, or behavior. - Order Date: 12/04/24, Weigh weekly on Monday, change to daily if Congestive Heart Failure (CHF), new diuretic, etc. Notify provider for loss or gain five lbs. or more in seven days. Every day shift every Monday. Review of Resident #295's medical record showed: - On 12/04/24, Resident #295 weighed 188.0 lbs. - On 12/04/24, a Nutritional Assessment was completed on Resident #295. In this assessment staff documented that Resident #295 was at risk for malnutrition. - On 12/05/24, a second Nutritional Assessment was completed on Resident #295. Again, staff documented that the resident was at risk for malnutrition. - On 12/09/24, Resident #295 weighed 176.2 lbs. This calculated to a loss of 11.8 lbs., or 6.2% in five days. - On 12/10/24, a third Nutritional Assessment was completed on Resident #295. In this assessment staff documented that they did not know if the Resident had any weight loss in the last three months and left the assessment incomplete, failing to document a completed nutritional status on the resident. - The percentage of weight gained and lost was calculated by the facility's electronic medical record program and the resulting calculation was visible to staff reviewing the resident's weights. - No documentation of notification made to Resident #295's Primary Care Provider related to significant weight loss. - No documentation of notification made to the RD related to specific request for individualized recommendations. 3. Review of Resident #244's undated Care Plan showed: - The resident is receiving the antidepressant medication duloxetine relating to depression. Staff are expected to monitor/document/report to the doctor (MD), signs and symptoms of depression unaltered by the prescribed medication, one of which is changes in weight. - The resident is at risk for psychosocial well-being problems related to social isolation. Staff are expected to monitor/document/report to the MD, signs and symptoms of depression. - The resident is at risk for nutritional problems related to impaired mobility and risk for malnutrition. Staff are expected to monitor/document/report to the MD, signs and symptoms of malnutrition, including significant weight loss. Review of Resident #244's medical record showed: - On 11/12/24, Resident #244 weighed 146.0 lbs. - On 11/20/24, Resident #244 weighed 139.1 lbs. This calculated to a loss of 6.9 lbs., or 4.7% in seven days. - On 11/27/24, Resident #244 weighed 140.0 lbs. - On 11/27/24, a Nutritional Assessment was completed on Resident #244. In this assessment staff documented that Resident #244 had a normal nutritional status, with no weight loss during the last three months. - On 11/28/24, a Comprehensive Nutritional Assessment was completed on Resident #244. In this assessment staff documented that Resident #244's weight history was not applicable, the resident had no weight change, and that the RD had no recommendations at this time. - On 12/02/24, Resident #244 weighed 146.2 lbs. This calculated to a gain of 6.2 lbs., or 4.4% in five days. - The percentage of weight gained and lost was calculated by the facility's electronic medical record program and the resulting calculation was visible to staff reviewing the resident's weights. - No documentation notification was made to Resident #18's Primary Care Provider related to significant weight fluctuations. - No documentation notification was made to the RD related to specific request for individualized recommendations. 4. Review of Resident #294's undated Care Plan showed: - Resident had potential for nutritional problem related to impaired balance and mobility. Staff are expected to monitor/record/report to the doctor (MD), signs and symptoms of malnutrition including significant weight loss. - Resident had potential for fluid deficit related to diuretic (a medication used to flush fluids from the body) use. Staff are expected to monitor/record/report to the MD, signs and symptoms of dehydration including recent/sudden weight loss. - Resident had a diagnosis of Diabetes and staff are expected to monitor for signs and symptoms of hyperglycemia (elevated blood sugar), one of which is weight loss. Review of December Physician Orders showed: - Start Date: 12/07/24 Torsemide Oral Tablet 20 milligrams (mg) Give one tablet by mouth every 24 hours as needed for diuretic related to unspecified diastolic congestive heart failure (a chronic condition that causes the heart to pump blood less effectively than it used to) administer an additional 20 mg for weight gain of two-three lbs. in one day or five lbs. in one week. - Start Date: 12/07/24 Torsemide Oral Tablet 20 mg Give one tablet by mouth in the morning related to unspecified diastolic congestive heart failure. Review of December's Medication Administration record showed: - The resident was not administered any as needed doses of Torsemide for weight gain between 12/01/24 to 12/13/24 - On 12/08/24 a one time only dose of Torsemide 20 mg was administered to the resident for shortness of air (SOA)/congestion. Review of the medical record showed: - On 12/06/24, Resident #294 weighed 211.4 lbs. - On 12/08/24, Resident #294 weighed 208.4 lbs. This calculated to a loss of 3.0 lbs. in two days. - On 12/10/24, Resident #294 weighed 200.2 lbs. This calculated to a loss of 8.2 lbs., or 3.9% in two days. - In total, Resident #294 lost 11.2 lbs., or 5.29% in four days. - The percentage of weight loss was calculated by the facility's electronic medical record program and the resulting calculation was visible to staff reviewing the resident's weights. - No documentation notification was made to Resident #294's Primary Care Provider related to significant weight loss. - No documentation the provider was made aware of the resident's 3.0 lbs. weight loss prior to administration of the ordered onetime only dose of Torsemide. - No documentation notification was made to the RD related to specific request for individualized recommendations. During an interview on 12/11/24 at 8:25 A.M., LPN C said: - Residents are weighed before breakfast. - If a resident has to be weighed in their wheelchairs, the weight of the wheelchair and whether or not the wheelchair should have the peddles on or off while weight is being obtained, is written on the back of the wheelchair. The weight of the wheelchair is then subtracted from the total weight obtained with the resident in the wheelchair on the scale. -Scales are checked and calibrated regularly but he/she's not sure by whom. He/She thinks it's done by an outside company. -He/She is unaware of any residents currently on the floor with weight loss or weight gain concerns. -If a resident gains or loses three lbs. in 24 hours or five lbs. in one week, staff is supposed to call the doctor. -If staff contacts the doctor it is charted in PCC (the facility's electronic medical record program) -Residents taking diuretics are supposed to be weighed daily. During an interview on 12/11/24 at 9:12 A.M., Speech Language Pathologist A said: -Speech works with the facility's nutritionist and follows the resident's weight. -He/She is not aware of any residents with a weight gain or weight loss concerns. During an interview on 12/11/24 at 8:44 A.M., Maintenance Technician said: -The Maintenance department checks and calibrates scales annually. -Scale checks and calibrations are documented in the maintenance log/compliance book. -He/She doesn't know when scales were last calibrated. During an interview on 12/13/24 at 7:52 A.M. DM A said: -Nutritional Assessments are completed by him/her or another dietary manager. -Comprehensive Nutritional Assessments are completed by the RD. -He/She isn't sure if nutritional assessments are reviewed by nurses or doctors. During an interview on 12/13/24 at 10:52 A.M. the DON said: -There are two Dietary Managers employed with the facility and each of them has a food manager's certification. -Dietary Manager Assessments are completed by the Registered Dietician (RD). -Nutritional Assessments are reviewed by nurses during risk meetings. -If a resident's nutritional assessments or weight shows a decline over time, it would be expected that the dietician and a dietary manager would discuss different processes to be put in place. -Both CNAs and Nurses weigh residents. -Scales are checked and calibrated quarterly. -A total of three pounds gained or lost in one day or five pounds gained or lost in one week would require a call to the Provider. -When a resident is identified as having a significant weight gain or loss they are discussed each week. -An order for a diuretic would not change the parameters laid out in the facility's policy for what would be considered significant weight gain or loss and if those parameters are met, it is expected that staff would contact the provider. During an interview on 12/13/24 at 10:52 A.M. the Administrator said: -Dietary Managers are expected to complete Nutritional Assessments and the RD is expected to complete Comprehensive Nutritional Assessments weekly. -Nutritional Assessments are expected to be completed with 24-48 hours after admission. -Scales are checked and calibrated by an outside company. -Wheelchairs are expected to be weighed each time residents requiring wheelchairs are weighed.

Based on interview and record review, the facility failed to complete a criminal background check for for five of 10 sampled employees prior to employment start date and evaluate for history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit and prevent such abuse, consistent with the applicable requirements at subsection S483.12(a)(3). The facility census was 40. The facility's Abuse, Neglect, and Exploitation Policy stated: - [NAME] Plaza at Briarcliff has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation, or misappropriation of property by any perpetrator including but not exclusive to any staff member or volunteer of this facility or any contracted agency staff, vendors, another resident, family member, or visitors of the resident or other residents. - The purpose of the components of this policy is to ensure that all residents of this facility will be free of physical, emotional, and sexual abuse, neglectful treatment and misappropriation of funds and resources. -The accompanying procedures are employed to assure total staff adherence to this policy. -The objective of the Abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. -Overview of seven components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting and Response. -It is the policy of [NAME] Plaza at Briarcliff to screen residents prior to moving into the facility as well as employees and volunteers prior to working with residents. -Screening of employee and volunteer components include verification of references, certification and verification of license, criminal background checks, and query of the Family Care Safety Registry. -All potential employees' names will be submitted to Validity Background Checks prior to their employment. Review of the facility's New Hire employee packets reviewed for Employee Disqualification List (EDL), Criminal Background Check (CBC) and Federal Indicator Checks showed: -Five of the 10 employees randomly selected had a date of hire prior to the date CBC results were received. -Maintenance Employee A was hired on 11/07/24. His/Her CBC results were received by the facility on 11/21/24. -Cook C was hired on 10/03/24. His/Her CBC results were received by the facility on 10/07/24. -CNA G was hired on 08/08/24. His/Her CBC results were received by the facility on 08/15/24. -Housekeeper A was hired on 07/11/24. His/Her CBC results were received by the facility on 07/15/24. -Activity Assistant A was hired on 10/11/24. His/Her CBC results were received by the facility on 06/03/24. During an interview on 12/13/24 at 10:52 A.M., the DON said: -An employee's hire date is their first day of orientation. -All background checks are completed by HR/Staffing Coordinator. During an interview on 12/13/24 at 10:52 A.M., the Administrator said: -An employee's hire date is their first day of orientation. -HR ensures all new employees have ben through the EDL, Nurse Aid Certification Check, and runs background checks.

Based on interviews and record review, the facility failed to ensure an invoked (activated by verifying incapacity of the resident to make decisions) Durable Power of Attorney (DPOA) was in place prior to allowing the designated agent to sign Outside of Hospital Do Not Resuscitate (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, or CPR, if the resident's breathing stops or if a resident's heart stops beating) forms which affected two of the 12 sampled residents, (Resident #22 and #18). Additionally they facility failed to ensure Resident #295's code status matched his/her's care plan. The facility census was 40. Review of the facility's undated policy for advance directives, showed: - It is the policy of the facility to comply with applicable law and to promote the right of self-determination by encouraging the use of Advance Directives (a legal document which allows your to plan and make your own end-of-life wishes known in the event your are unable to communicate)and honoring treatment preferences expressed by the resident and/or the resident's representative and their Advance Directives, if those preferences are allowed by law; - Prior to or on admission, the Social Worker or designee will ask the resident or resident's representative, if they have a a Living Will (a written, legal document that spells out medical treatments you wound not want to be used to keep you alive, as well as your preferences for other medical decisions) or DPOA for health care decisions; - All residents will be given written information concerning an individual's rights under state law, to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives; - If the resident has any of these Advance Directives, a copy of the documents will be placed in the resident's medical record and reviewed quarterly, annually and as needed with the resident; - If the resident becomes incapacitated, the resident's representative will be contacted quarterly, annually and as needed; - If the resident is in a coma or incapacitated, the information about Advance Directives shall be given to the family or resident's representative. 1. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed: - Long and short term memory problems; - Lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene and transfers; - Diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), progressive neurological disorder (condition where there is a progressive deterioration in functioning), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and dementia (inability to think). Review of the resident's care plan, revised [DATE] directed staff the resident's code status was a do not resuscitate and the resident wanted to have his/her wishes honored. Review of the resident's face sheet showed the responsible party was the resident's spouse. Review of the resident's medical record showed: - The resident's spouse signed the purple OHDNR form on [DATE] and the physician signed it on [DATE]; - Unable to locate the resident's incapacitation letter in the resident's medial record. During an interview on [DATE] at 2:53 P.M., the Social Services Director (SSD) said he/she was looking for the resident's advance directives and the incapacitation letter. During an interview on [DATE] at 9:41 A.M., the SSD said she found the resident's advance directive but was unable to locate the resident's incapacitation letter. During an interview on [DATE] at 10:52 A.M., the Director of Nursing (DON) said if a resident was not their own person and had a DPOA in place, she would expect there to be an incapacitation letter in the residents medical record. 46706 2. Review of Resident #18's Quarterly Minimum Data Set, dated dated [DATE], showed: - Severe cognitive impairment; - Dependent on staff for activities of daily living (ADLs); - Frequently incontinent of bowel and bladder; - Diagnoses included Alzheimer's disease, aphasia (disorder that makes it difficult to communicate), and high blood pressure. A review of the resident's care plan dated [DATE] showed: - The resident has an ADL self care performance deficit related to limited mobility; - DNR (Do Not Resuscitate) code status. Review of the resident's medical record showed: - Physician's order dated [DATE]: DNR code status; -OHDNR (Out of Hospital Do Not Resuscitate) signed by the resident's husband and physician on [DATE]; -No DPOA paper work was found; -No letter of incapacitation was found. During an interview on [DATE] at 11:45 A.M., the SSD said: -The resident should have a letter of incapacity; -If a resident is deemed incapacitated there should be a letter with that information; -DPOA and incapacitation information should be obtained at admission and placed in the resident's chart; -He/she could not locate the resident's DPOA or incapacity letter. 51626 3. Review of Resident #295's Face Sheet (a document meant to be a quick summary of a resident's essential information) showed: -The resident is his/her own person (there is no other person assigned by the resident or the courts that would be responsible for making the resident's healthcare and/or end-of-life decisions). -The resident's Code Status is listed as unknown. -The Advanced Directive reads the resident's code status is listed as DNR. Review of Resident #295's medical record showed: -The resident had a Basic Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact and capable of making his/her needs and desires known. -The resident signed a Code Status Form dated [DATE] and checked the DO NOT RESUSCITATE box. The form was witnessed by LPN C. -The resident's New Admission Report Sheet, completed by an unknown staff member, lists the resident's code status as Full Code. -The resident's Medication Administration Record lists the resident's Advance Directive status as both a Full Code and a DNR. Review of Resident #295's care plan updated [DATE] directed staff the resident was to be a FULL CODE. Review of Resident #295's Physician Orders showed a DNR, order dated [DATE]. During an interview on [DATE] at 2:34 P.M., Resident #295 said he/she has a DNR and he/she expects his/her wishes to be honored. During an interview on [DATE] at 8:25 A.M., LPN C said: -If a resident is a DNR, there would be a butterfly sticker on the back of their door. Plus, they would have a purple DNR sheet in the book at the desk. -Resident's Advance Directive paperwork can be found on the computer. -A resident's code status is listed in their care plan, on their face sheet, in provider orders. -The code status listed in all these places are the same. During an interview on [DATE] at 7:55 A.M., LPN B said: -If a resident is a DNR, it would be in the binder at the desk or all over in their chart. -A resident's code status should be the same in each place in their chart. During an interview on [DATE] at 10:52 A.M. the Director of Nursing (DON) said: -If a resident is a DNR status, they would have a physicians order in the computer as well as a DNR form completed in the binder located at each nurse's station. -A resident's advanced directive can be found in the computer on the physician's order sheet, on the face sheet, and when the Medication Administration Record (MAR) is pulled up. -A resident's code status is listed in their care plan. -The code status in the care plan should match the code status in the provider's orders. During an interview on [DATE] at 10:52 A.M., the Administrator said: -A resident's code status is expected to be the same throughout their chart. -Whatever code status is listed in the provider's orders should be the code status in the care plan.

Based on observation and interviews, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain and replace holes in carpet, vacuum and sweep floors, clean stained furniture, repair scraped and missing paint from walls, clean and maintain food and medication carts, replace stained ceiling tiles, and clean facility windows. The facility census was 40. Review of facility policy, Cleaning and Infection Control of Non-Critical, Reusable Resident Care Equipment, undated, showed: -Cleaning-the physical removal of foreign material, e.g. dust, oil, organic material such as blood, secretions, excretions, and micro-organisms -Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms -Cleaning is accomplished with water, detergents/sanitizers, and mechanical action; -Cleaning is a shared responsibility between nursing and housekeeping departments; -All equipment must be cleaned immediately if visibly soiled, and immediately after use on elders with contact precautions regardless of cleaning schedule; -All neighborhoods will set up a schedule for cleaning with specific assignments to ensure tasks are completed; -All horizontal and frequently touched surfaces will be cleaned daily and immediately when soiled; -The Housekeeping manager and the Infection Practitioner must approve all products used for the stages of cleaning/disinfection process; Review of facility policy, quality of care, undated, showed: -Facility is committed to providing high quality of care and services to residents in a safe, respectful, and person-centered environment. -Safety and Security -Ensuring the safety and security of residents is paramount; -Facility adheres to all relevant safety protocols, infection control measures, and emergency procedures to maintain a secure environment. Observation in the dining room on 12/10/24 at 11:29 A.M., showed several areas on all walls where the paint had been scrapped off and was missing from the walls showing white through the dark gray colored paint. One 8 inch by 3 inch area was noted on the back wall by the windows. Observation on 12/10/24 at 12:14 P.M. showed a three tiered metal cart was being used to deliver resident meal trays. The cart was observed to have sticky food like substance caked to the bottom rim of the metal cart unit. The wheels on cart were also observed to be caked in dirt. Observation on 12/11/24 at 8:29 A.M. showed sitting area by patio on east hall had food crumbs located under all four chairs in seating area and the end tables. Observation on 12/11/24 at 8:33 A.M. showed the floor on east hall nurses station had food crumbs, pieces of torn paper, paper clips, and other particles laying on floor. Observation on 12/11/24 at 8:34 A.M. of medication cart on east hall showed the wheels on medication cart were covered and wrapped with appeared to be human hair. The ledges of the bottom of the medication cart also had grime and dirt built up. Observation on 12/11/24 at 8:35 A.M. showed a discolored ceiling tile above sitting area on east hall by patio. Observation on 12/11/24 at 8:37 A.M. showed on east hall there was a 4 inch by 1 inch area that was missing carpet where the blue carpet met white carpet. Areas of frayed carpet were also sticking up where the area of carpet was missing. Observation on 12/11/24 at 8:40 A.M. showed windows on east hall between room [ROOM NUMBER] and 2017 had dirt built up between the screens. Observation on 12/11/24 at 8:43 A.M. showed the stairwell exit door between resident rooms [ROOM NUMBERS] had a spilled sticky substance on it. Observation on 12/11/24 at 8:45 A.M. showed the pillar in the dining area across from room [ROOM NUMBER] had a spilled brown sticky substance on it. Observation on 12/11/24 at 8:49 A.M. showed the white portions of the carpet in the living room area had stains on it. Observation on 12/12/24 at 9:00 A.M. showed crumbs remained under chairs and end tables in on carpeted seating area by the patio on the east hall. Observation on 12/11/24 at 2:23 P.M., showed a PTAC (packaged terminal air conditioner) unit with a black mold-like substance on the fins of the heating/cooling unit in the janitor's closet by room [ROOM NUMBER]. 51626 Observation on 12/10/24 at 9:59 A.M. showed: -A window at the end of the rehab hallway, between resident #294's room and the room across the hall, with grime and debris cracked around its edges. -Resident #296 walking in the rehab hallway with a therapy staff member . The resident was overhead saying, That window needs to be cleaned, it looks disgusting! Observation on 12/10/24 at 9:59 A.M. showed: -A chair at the end of the rehab hallway, between resident #294's room and the room across the hall, with stains on the seat. Observation on 12/11/24 at 2:19 P.M. showed a hole in the carpet in resident #21's room. The hole measured approximately one (1) inch by six (6) inches. The hole had frayed carpet around the edges and was directly in the walking path in front of the bathroom door and posed a trip hazard. During an interview on 12/12/24 at 9:59 A.M., Housekeeping Supervisor said: -Maintenance was responsible to fix and repair walls; -The facility was currently understaffed with only four staff members in housekeeping for whole building; -The floor technician was responsible for vacuuming, maintaining floors, windows, and furniture in facility; -Due to the vacant position of floor technician the facility vacuuming and maintenance of the floors had been overlooked by his/her staff; -His/Her staff was primarily responsible for cleaning of the resident rooms; -The facility floor technician quit and facility had been without a floor technician for approximately a week; -He/She had her staff assist with the floor technician duties following completion of resident rooms; -If residents complained about the noise of the vacuum then he/she expected his/her staff to wait until resident was out of their room to vacuum or respect resident wishes and desires to keep the area quiet and not vacuum but try to hit the area with a broom; -He/She expected his/her staff to deep clean every day; -He/She expected his/her staff to respect resident wishes, if a resident did not want housekeeping in their room he/she expected staff to listen; -Housekeeping staff were expected to clean areas that floor technician missed and furniture in main areas; -The materials found on chairs in halls were cleaned with a steam cleaners; -Housekeeping staff were not allowed to clean the chairs due to risk of spotting the furniture; -He/She communicated with maintenance staff and floor technicians via email if he/she found area that needed addressed; -Resident rooms that were occupied by residents were cleaned daily; -If a room did not get cleaned one day then it was scheduled to be cleaned first the next day; -He/She expected his/her staff to clean resident's bathrooms first and then work their way out of the room by dusting, wiping down furniture items, and attending to the floor; During an interview on 12/13/24 at 9:06 A.M., Assistant Director of Nursing (ADON) B said: -The facility used a website for communication needs that were to be addressed by maintenance; -Nurses and facility administration had access to communicate maintenance needs via the website; -Certified nurses aids are to communicate any maintenance requests to nursing staff and nursing staff are to log the request for maintenance on the website. During an interview on 12/13/24 at 9:10 A.M., Maintenance Technician said: -He/She received work orders through the website work hub; -He/She was able to obtain supplies needed really quickly if did not have them in facility; -He/She was aware of holes in carpet, there is current plans to replace carpet in main areas; -He/She was currently working on resident room needs as first priority; -Facility had a floor technician responsible for cleaning and maintaining facility floors; -The floor technician position had been vacant for approximately one week; -He/She was responsible for wall repairs; -He/She was aware of repair needs required in dining room; -He/She had to get painters from other facility building to come in and paint in dining room. During an interview on 12/13/24 at 10:52 A.M., Administrator said: -She expected to provide a safe, clean, and home like environment for residents; -She expected food carts for room trays to be cleaned and sanitized; -She did not expect food carts to have food and other substances caked to bottom of carts; -She expected floors to be free from holes in carpets and trip hazards; -She expected facility floors to be free from debris, crumbs, and stains; -She expected facility floors to be vacuumed; -She expected walls to be maintained with dry wall patches made and walls painted; -She expected furniture to be free from stains and break down.

Based on interviews and record review, the facility failed to prevent one resident from falling (Resident #1). Staff identified the resident was at risk for falls. Staff left the resident unattended on the toilet and the resident fell and sustained a [MEDICAL CONDITION] clavicle (collarbone). The facility census was 22. Review of the undated facility policy for fall prevention showed: -Each resident will be provided cares and services that ensure their environment remains as free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for casual risk factors related to falling at the time of admission, upon return from a health care facility and after every fall in the facility; -High risk fall prevention protocol: the Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff assessment triggers the falls care area assessment (CAA), the CAA has included causal factors for determination of fall risk, the resident uses assistive devices or the physical assistance of one or two persons to transfer or ambulate, the MDS assessment identified challenges with short term and long term memory as well as decisions making or the resident has had a fall while living in the facility; -The Interdisciplinary Team will develop a plan for services to improve and/or maintain the resident's standing and sitting balance as well as other interventions to reduce the resident's risk for falls. The plan will include specific individualized information regarding the resident's routine and personal habits that may place the resident at risk for falls; -Every team member is responsible for checking the care plan of residents who are risk for falls when beginning each day and throughout the assigned shift. 1. Review of Resident #1's admission fall assessment dated [DATE] showed he/she was at high risk for falls. Review of the resident's Occupational Therapy (OT) evaluation dated 12/21/18 showed: -Referred to OT due to new onset of left stroke with right [MEDICAL CONDITION] (weakness of one entire side of the body), with decrease in strength, decrease in functional mobility, decrease in transfers, decrease in range of motion, reduced ability to safely ambulate, reduced balance, decreased neuromotor (nerves or muscle) control, reduced functional activity tolerance, decreased postural alignment, decreased coordination, reduced static and dynamic balance (moving from one position to another), increased need for assistance from others and reduced Activity of Daily Living (ADL) participation placing the resident at risk for further decline in function, falls, increased dependency upon caregivers, decrease in level of mobility, decreased ability to return to prior living environment and contractures (shortening of muscles or tendons); -Unable to stand independently, unable to bend over; poor sitting balance; -Right leg and arm are flaccid (lack of muscle control); -Poor trunk control and leans to the right. Review of the resident's Physical Therapy (PT) evaluation dated 12/21/18 showed: -Referred to PT due to new onset of left stroke with right [MEDICAL CONDITION], with decrease in strength, decrease in functional mobility, paresis (inability to move one side), increased need for assistance from others, reduced static (ability to maintain balance while not moving) and dynamic balance, reduced sensorimotor (process of receiving sensory messages and producing a response) skills, reduced functional activity tolerance, decreased neuromotor control, reduced ability to safely ambulate, decrease in transfers, reduced ADL participation and reduced balance placing the resident at risk for further decline in function, decrease in level of mobility and falls. Review of the admission MDS dated [DATE] showed: -Modified independence with decision making. Able to recall time, date and place; -Extensive assistance of two staff members for Activities of Daily Living (ADL's); -Occasionally incontinent of bladder; continent of bowel; -History of falls prior to admission; -Received anticoagulant therapy (medication to thin the blood) and diuretics (medication which increases urination); -[DIAGNOSES REDACTED]. Review of the undated care plan for ADL self care showed: -The resident required two staff with toileting transfers due to right sided weakness. Review of the undated care plan for falls showed: -The resident will be free of falls; -Ensure the resident's call light is within reach and encourage the resident to use the call light for assistance as needed. The resident requires prompt response to all requests for assistance; -The resident will be evaluated for and supplied adaptive devices such as wheelchair and bedside commode; -Educate the resident about safety reminders and what to do if a fall occurs; -Follow fall protocol. Review of the fall scene investigation report dated 1/12/19 at 12:15 P.M. signed by Registered Nurse (RN) A showed: -Unwitnessed fall; -Equipment malfunction: the commode came apart; -The resident was on his/her right side with legs straight and right arm in a sling; -No injuries noted at the time and no complaints of pain; -Certified Nurse Aide (CNA) A and CNA B transferred the resident from the wheelchair with a gait belt onto the commode over the toilet. Both CNA's went out of the room to assist other residents and left the resident with RN A. RNA A walked out of the resident's room to the door way to request help with transferring the resident from the commode to the wheelchair and when the CNA's went into the bathroom, the resident was on the floor; -The toilet seat of the commode over the toilet had popped off; -Root cause of the fall was the resident was left unattended and left alone while sitting on the toilet; -Interventions to prevent future falls showed the resident was not to be left unattended while on the toilet. Review of the nurses' notes dated 1/12/19 at 1:14 P.M. signed by RN A showed: -The resident found on floor in the bathroom with the commode apart. No injures noted at this time. Review of the nurses' notes dated 1/16/19 at 6:55 A.M. showed: -Large bruise on the right shoulder to the top of the chest. The resident did not complain of pain when the area is palpated or asked if the bruise hurt. Will continue to assess and monitor for changes. Review of the nurses' notes dated 1/16/19 at 10:15 A.M. showed: -The resident reassessed and he/she stated there was no pain in the right arm. There was swelling noted to the upper right chest. Received orders for an x-ray to the upper right extremity and chest. Review of the nurses' notes dated 1/17/19 at 1:16 P.M. showed: -X-ray results showed the resident had a distal [MEDICAL CONDITION] clavicle; -Nurse practitioner on call notified of the results of the x-ray and orders received to send the resident to the emergency room (ER) for further evaluation. Review of the nurses' notes dated 1/17/19 at 6:30 P.M. showed: -The resident returned from the ER with right arm in a sling. During an interview on 1/22/19 at 1:30 P.M. the Director of Nursing (DON) said: -CNA A and CNA B transferred the resident onto the commode over the toilet on 1/12/19. RN A entered the resident's room to administer medication then the CNA's left to answer call lights. RN A walked out of the resident's room to get assistance and left the resident unattended on the toilet. When CNA A and CNA B came into the room, the resident was on the floor. The resident's call light was not activated. The staff found that the seat of the commode over the toilet had come off and was on the floor next to the resident; -The resident was at high risk for falls; -The care plan or the abrade (a guide used by the CNA's to give care) did not indicate that the resident could be left unattended while on the toilet; -Prior to the fall ,there was no instructions for the nursing staff for safety while on the toilet. During an interview on 1/22/19 at 2:00 P.M. the Certified Occupational Therapy Aide (COTA) said: -The resident could not put his/her feet on the floor while sitting on the toilet; -The resident was not safe to be left alone on the toilet. During an interview on 1/22/19 at 2:10 P.M. the Occupational Therapist (OT) said: -The resident was unable to move his/her right side; -The resident should not have been left alone on the toilet. During an interview on 1/23/19 at 10:25 A.M. CNA A said: -The resident required two staff members to transfer; -The resident could not use his/her right side and would lean to the right; -He/she and CNA B transferred the resident to the toilet around 11:45 A.M. on 1/12/19; -The resident indicated that he/she needed to have a bowel movement; -RN A came into the room to give the resident his/her medication; -When he/she and CNA B left the room, RN A was with the resident in the bathroom; -Several minutes later, RN A was in the doorway of the resident's room telling him/her that the resident was done in the bathroom; -He/she and CNA B went into the resident's room and the resident was on the floor; -The seat from the commode that was over the toilet was off and laid next to the resident; -He/she, CNA B and RN A got the resident off the floor and into the wheelchair; -The resident did not complain of any pain. -There was no instructions on the care plan for toilet safety; -He/she would not have left the resident on the toilet if the care plan indicated the resident was not safe to be left on the toilet. During an interview on 1/23/19 at 10:42 A.M. RN A said: -CNA A and CNA B transferred the resident onto the toilet on 1/12/19 before lunch; -He/she went into the resident's room to administer medications; -CNA A and CNA B left the room to assist other residents, while he/she was in with the resident; -He/she stepped out of the resident's room to get help to get the resident off the toilet; -He/she was only out of the resident's room for approximately one minute; -He/she did not hear the resident fall; -CNA A and CNA B went into the resident's bathroom and found the resident on the floor; -He/she, CNA A and CNA B got the resident off the floor; -The resident did not complain of pain or showed any signs of injuries; -The resident was generally not left unattended while on the toilet; -The resident had right side paresis and poor trunk control and would lean to the right side; -He/she was unaware of any instructions for the staff regarding toilet safety; -He/she would prefer the staff stay with the resident while on the toilet. During an interview on 1/23/19 at 11:00 A.M. CNA B said: -He/she and CNA A transferred the resident onto the toilet around 11:45 A.M. on 1/12/19; -He/she and CNA B left the room to answer call lights when RN A came to give the resident his/her medications; -RN A left the resident on the toilet and came out into the hallway and informed him/her and CNA A that the resident was ready to be transferred into his/her wheelchair; -When he/she and CNA B went into the bathroom the resident was on the floor; -The seat of the commode that was over the toilet was on the floor next to the resident; -He/she used the Kardex for instructions on how to give resident's care; -He/she does not remember any instructions for toilet safety for the resident; -He/she had only left the resident on the toilet alone one other time; -He/she did not feel that the resident was safe to be left on the toilet alone; -He/she did not see any safety instructions for the resident on the Kardex or the care plan; -The resident should not have been left alone on the toilet. During an interview on 1/23/19 at 2:00 P.M. the DON said: -The resident should not have been left alone on the toilet; -The care plan and the Kardex should have had instructions for the staff for safety while on the toilet. MO 7